THE LECTURES OF BOTER 

UPON 

DISEASES OF THE BONES, 

ARRANGED INTO A SYSTEMATIC TREATISE, 

BY A,JUCHERAND, 

PROFESSOR OF ANATOMY AND PHILOSOPHY, AND PRINCIPAL SURGEON 
TO THE NORTHERN HOSPITAL AT PARIS. 

ILLUSTRATED WITH PLATES. 

TRANSLATED FROM THE FRENCH 

By M. FARRELL, M. D. 

/ 

TWO VOLUMES IN ONE. 
mi <$& m m 

THE FIRST AMERICAN EDITION, 

WITH 

NOTES AND ADDITIONAL PLATES, 
By JOSEPH HARTSHORNE, M. D. 



PRINTED AND SOLD BY JAMES HUMPHREYS, 
Corner of Second and Walnut -streets. 




7 

Districl of Pennsylvania, to wit : 

BE IT REMEMBERED that on the fifth day of August, 
in the thirtieth year of the Independence of the United States of Ame- 
rica, A.D. 1805, Joseph Hartshorne, of the said districl, hath de- 
posited in this office the Title of a Book, the right whereof he claims as 
Proprietory in the words following, to wit : 

" The Lectures of B oyer upon Diseases of the Bones, arranged 
" into a Systematic Treatise, by A. Richer and, Professor of Ana- 
f tomy and Philosophy, and Principal Surgeon to the Northern Hos- 
" pital at Paris — 'Illustrated with Plates — Translated from the 
t( French by M. F.arrel, M.D. — Two Volumes in one. — The first 
*< American Edition, with Notes and Additional Plates, by Joseph 
*< Hartshorne, M. D." 

In conformity to the acl of the Congress of the United States, intituled, 
ft an Acl for the encouragement of learning, by securing the copies of 
maps, charts, and books, to the authors and proprietors of such copies 
during the times therein mentioned'''' — and also to the ad entitled, ** an 
acl supplementary U an acl, entitled, " an acl for the encouragement of 
learning, by securing the copies of maps , charts, and books, to the authors 
and proprietors of such copies during the times therein mentioned" and 
extending the benefits thereof to the arts of designing, engraving, and 
etching historical and other prints " 

D. CALDWELL, 

Clerk of the Districl of Pennsylvania. 



TRANSLATORS PREFACE, 



THE celebrity of the Authors of this Treatise 
entitles it to a considerable share of attention. 
Boyer, a distinguished professor of surgical pathology, 
and an eminent practitioner of surgery, who is the 
principal author, would have contented himself with 
delivering the substance of it in his public Lectures, 
had not some of his pupils attempted to publish from 
their notes a spurious edition of the work. These 
copyists presented Boyer's doctrine in so mutilated 
a form, that it was found necessary to give a genuine 
edition of the Lectures to the public. Richerand, 
professor of anatomy and physiology, and practitioner 
of surgery, in which department he has distinguished 
himself by his writings,* at the request of his friend 
Boyer, and immediately, under his inspection, under- 
took this task: but he has not confined himself to the 
duty of a compiler; he has enriched the work by 
many of his own observations, 

The want of a complete treatise in English, on 
the Diseases of the Bones, must have been felt by 
students in surgery. The present work, it is pre- 

* See Professor Richerand's Elements of Physiology, translated 
from the French by R. Kerrison, 8vo. printed for J. Murray, 34, 
Fleet-street. 



iv translator's preface. 

sumed, will not only fill up this deficiency, but faci- 
litate the study of surgery, and expedite the progress 
of those who devote themselves to that branch of 
medical knowledge. 

A scrupulous attention has been paid to preserve 
the precise meaning of the authors. Their ideas 
have been rendered in plain and intelligible language . 
and it is hoped that the work, as it is now presented 
to the public, will answer the same purposes to the 
English reader, that the original does to the French. 



ERRATA. 

Page ii, line 10 from the bottom, for astragolos read astragalus. 
34, line 17, for though read through. 
40, line 2, for Fabrlce de Hilden read Fabricius Hildanus.* 

44, line 20, for analogously read analogous.* 

45, line 11 from the bottom, and page 82, line 10 from the bottom,. 

for Ledran read he Dran.* 
109, line 7, for tear read bear. 
116, line 2 from the bottom, for greatb read great. 
121, line 22, dele the.*. 

121, line 4 from the bottom, for Hook read Gooch.f 
156, line 5 from the bottom, for parietal read parietal.* 
243, line 2 from the bottom, for advantage read disadvantage. 
251, line 3 from the bottom, for latterly read laterally* 
305, line 4, for bare read bear. 



* These are errors of the London copy. 

f This also is an error, (and probably a typographical error), of the London 
edition. See Benjamin Bell's System of Surgery, or GooeVs Medical and Chirur- 
gical Observations. • 



CONTENTS. 



VOLUME I. 

PAGE 

Introduction 9 

CHAPTER I. 

Of Fractures in ceneral n 

§ I. Of the different Species of Fraclure . . . . ib. 

§ 2. Of the Causes of Fraclures 1 8 

§ 3. Of the Signs of Fractures 19 

§ 4. *The Prognosis of Fractures 21 

§ 5 . Of the Treatment of Fraclures ...... 2 3 

§ 6. Of the Formation of Callus 36 

CHAP. II. 
Of the Fractures of the Bones of the Nose 46 

CHAP. III. 
Of the Fractures of the Lower Jaw . . . 218 

CHAP. IV. 

Of the Fractures of the Vertebra ... 54 

CHAP. V. 
Of the Fractures of the Sternum .... 57 

CHAP. vr. 
Of Fractures of the Ribs 59 

CHAP. VII. 
Of Fractures of the Bones of the Pelvis . 64 

§ I. Of Fraclures of the Sacrum ........ ib. 

§ 2. Of Fraclures of the Os Coccygis . . . . . 65 
§ 3. Of Fraclures of the Ossa innominata ... 66 

CHAP. VIIL 
Of Fractures of the Scapula 68 

CHAP. IX. 
Of Fractures of the Clavicle 72 

CHAP, X. 
Of Fractures of the Humerus 78 



VI CONTENTS. 

CHAP. Xr. PAGE 

Of Fractures of the Fore-arm 83 

§ I. Of ' Fraaures cf both the Bones ..... 84 

§ 2. Of Fraaures of the Radius 87 

§ 3- Of Fractures of the Cubitus 88 

§ 4. Of Fradures of the Olecranon 89 

CHAP. XII. 

Of Fractures of the Bones of the Hand . . 93 

§ I. Of Fraaures of the Bnes of 'the Carpus . ib. 

§ 2. Of Fraaures of the Bones of the Metacarpus ib. 

§ 3. Of Fractures of the Phalanges of the Fingers . . 94 

CHAP. XIU. 

Of Fractures of the Thigh 96 

CHAP. XIV. 

Of Fractures of the Neck of the Femur . . 102 

CHAP. XV. 
Of Fractures of the Patella 129 

CHAP. XVI. 

Of Fractures of the Bones of the Leg . , . 143 

§ 1 . Of Fraaures of both the Bones ....... ib. 

§ 2. Of Fraaures of the Tibia . . 1 47 

§ 3. Of Fraaures of the Fibula 148 

CHAP. XVII. 
Of Fractures of the Bones of the Foot . . 152 

CHAP. XVIII. 
Of Wounds, and Denudation, of Bones . . . 154 

CHAP. XIX. 
Of Necrosis 157 

CHAP. XX. 
Of Caries 164 

CHAP. XXI. 
Of Exostosis 1 7& 

CHAP. XXII. 
Of Osteo-sarcoma • I & 2 



CONTENTS, VU 

VOLUME II. 



CHAP. I. PAGE 

Of Rickets 189 

CHAP. IT. 

Of the Fragility of Bones 197 

CHAP. III. 
Of Sprains • 199 

CHAP. IV. 

Of Luxations in general ■ . . 204 

§ 1. Of the Differences of Luxations 205 

§ 2. Of the Causes of Luxations 207 

§ 3. Of the Symptoms of Luxation ....... 209 

§ 4. Of the Prognosis in Luxations 211 

§ 5. General Treatment of Luxations . . . . . . .212 

CHAP. V. 
Of Luxations of the Lower Jaw 220 

CHAP. vr. 

Of Luxations of the Vertebra 225 

§ 1. Of Luxations of the Head from the first Vertebra . 226 
§ 2. Of Luxations of the first cervical Vertebra from the 

second ib. 

CHAP. VII. 
Of Luxations of the Bones of the Pelvis . . 230 

CHAP. VIII. 

Of Luxations o.f the Clavicle 234 

§ I. Of Luxations of the Extremity next the Sternum . . ib. 
§ 2. Of Luxations of the Extremity next the Humerus . . 237 

CHAP. IX. 
Of Luxations of the Os Humeri ...... 239 

CHAP. X. 

Of Luxations of the Fore-arm 251 

§ 1. Of Luxations of the Fore-arm from the Humerus . • ib. 
§ 2. Of Luxations of the superior Extremity of the Radius 

from the Ulna • 255 

§ 3. Of Luxations of the inferior Extremity of the Ulna . 257 



Vlll CONTENTS. 

CHAP. XT* page 

Of Luxations of the Hand 259 

§ I . Of Luxations of the Wrist ib. 

§ 2. Of Luxations of the Bones of the Carpus and Met a- 

carpus 261 

§ 3. Of Luxations of the Fingers 262 

CHAP. XII. 
Of Luxations of the Femur 264 

CHAP. XIII. 
Of Spontaneous Luxations of the Femur . . 271 

CHAP. XIV. 
Of Luxations of the Patella • 278 

CHAP; XV. 

Of Luxations of the Bones of the Leg . « . 282 

CHAP. XVI. 
Of Luxations of the Foot 284 

CHAP. XVII. 
Of Dropsy of the Articulations 288 

CHAP. XVIII. 
Of Foreign Bodies formed in the Articu- 
lations 293 

CHAP. XIX. 
Of Wounds of the Articulations 297 

CHAP. XX. 
Of White Swellings of the Joints 301 

CHAP. XXI. 
Of Anchylosis 310 

CHAP. XXII. 
Of the Deviations of Bones, and the Means 
used for Preventing and Correcting the 
Deformity arising from them 314 

ANALYTICAL INDEX ; 321 

NOTES 357 



A TREATISE : 

Eft. 



INTRODUCTION. 



BONES are subject to the same diseases as the soft parts. This 
assertion may at first appear to be made at random, but its 
truth will be proved by the explanation into which we are about to 
enter. Hardness, which is their distinctive quality, does not belong 
to them in every stage of their existence ; their soft and gelatinous 
state in the embryo is changed in a more advanced stage of life to 
that of cartilage, which finally hardens by the deposition of a 
neutralized combination of lime and phosphoric acid, in its pa- 
renchymatous structure. To this saline inorganized substance is to 
be ascribed whatever difference is found between the bones and 
soft parts. When deprived of this substance, whether artificially, 
by immersion in an acid, or by the operation of the disease call- 
ed rachitis, they become soft and flexible, and are reducible, by 
long maceration, to a cellular structure, in which vessels of every 
species are seen to ramify. 

The existence, however, of the phosphate, and of a small 
quantity of carbonate of lime in bones, has a great influence on 
their diseases; the circulation is in some degree obstructed by the 
presence of this inorganized matter, and all the vital properties 
are thereby rendered more obscure. Thus all the diseases of the 
bones, which depend on a greater or less excitement of these 
properties, are slow in their progress, and of the chronic kind, 
although similar affections of the soft parts would produce acute 
diseases. A solution of continuity, for instance, or a simple 
wound of the soft parts, heals and reunites in two or three days, 
if the parts be brought into immediate contact, but a wound or 






IO INTRODUCTION. 

fracture of a bone requires twenty days at least, not unfrequentlsf 
forty or fifty, and even several months in some cases; and in ge- 
neral it may be said, that the cure will be slow in proportion to 
the person's age; because, as years increase, the proportion of 
the saline part of the bones increases also. 

How much greater is the duration of exostosis than of phleg- 
mon or any other swelling of the soft parts? Is not necrosis, 
which is the true gangrene of the bony substance, equally slow? 
Is not the separation of the living from the mortified part slower 
than in the gangrene of soft parts? This long duration of these 
diseases, and the tardy succession of their symptoms, will be 
greater or less in proportion to the greater or less relative quanti- 
ty of saline matter in the bones; whence it follows, that their 
progress will be quicker in the infant than in the adult, and, ceteris 
paribus, that they will be slower in old age than at any other pe- 
riod. 

The best and most ancient division of the diseases of the bones 
is that which distributes them into two orders; the first of which 
comprehends whatever affects each bone singly, in its substance 
or continuity; the second comprehends their diseases in the 
joints, and in their points of contact one with another. But it is 
to be oberved, that the diseases of this second order may affect 
also the substance of the bones, as, frequently, in cases of white 
or lymphatic swellings of the joints, caries of the extremities of 
the bones accompanies the morbid affection of the surrounding 
soft parts. 

The first order of the diseases of the bones comprehends their 
fractures, wounds, exostosis, necrosis, and caries, the ricketty 
softening of the bones, their friability, and that morbid state 
known by the name of spina ventosa, or osteosarcoma. 

The second order embraces sprains, luxations, dropsy of the 
articulations, the diseases arising from preternatural substances 
generated in the articulations, white or lymphatic swellings, and 
anchylosis. 

It shall be shewn in the sequel, that the assistance of art is 
indispensable, and efBcacious in the greater number of these dis- 
eases* Whatever relates to fractures shall first be considered: Of 
ail the diseases of the bones they are the most frequent; to none 
is a strict attention more necessary; in the treatment of none is 
the utility of the surgical art more evident. 



II 



CHAPTER I. 



OF FRACTURES IN GENERAL. 

FRACTURE is defined a solution of continuity of one or of 
several bones, resulting from a force of extension dispropor- 
tionate to, and exceeding their natural extensibility. We shall not, 
in imitation of the greater part of authors, add, " produced by 
some external cause*," for though the most usual cause of fractures 
be some external force, yet muscular force is sometimes the sole 
cause. It is this alone that always occasions the fracture of the 
patella, olecranon, and calcaneum. This definition might be ap- 
plied to a solution of continuity produced by a cutting instrument, 
and therefore very different from fracture properly so called; but 
a rigorous precision of language is not to be expected, particular*- 
ly in medical subjects. 



SECTION I. 

Of the different Species of Frablure. 

Fractures differ from one another in five respects; 1st, as to 
the bone affected; 2d, as to the part of the bone; 3d, as to the 
direction of the fracture; 4th, as to the relative position of the 
fractured portions; 5thly, and finally, as to the attending circum- 
stances by which the fracture may be either simple, or variously 
complicated. We proceed to consider them successively in these 
respects. The fractured bone may be broad, such as the scapula, 
or bones of the pelvis; or short, as the calcaneum and astragolos; 
or belong to the class of long bones, as is most frequently the 
ease. The situation and use of the broad bones do not expose 
them much to be fractured, with the exception, however, of 
those of the cranium; in which case, the fracture is less to be at-? 
tended to than the affection of the brain, which it almost neces- 
sarily occasions. 

The fracture of short bones is still less frequent, on account of 
the equality of the three dimensions; and if not produced by an 
external force or weight, which crushes, or rather grinds the part, 



12 OF FRACTURES IN GENERAL, 

is almost always produced by muscular contraction, which is by 
much the most frequent cause of the fracture of the patella, of 
the olecranon, and calcaneum. The long bones, whether they 
serve as pillars, as levers, or as arch-ending points of support 
and resistance, are much exposed to fracture, and are more fre- 
quently fractured than any other class of bones; therefore, all 
that is to be said of fractures in general, is principally applicable 
to them. 

These bones may be fractured in different points of their 
length, and that happens most frequently in the point of bisec- 
tion; in which case, the fracture is produced, like that of a stick 
bent beyond its natural extensibility, by a force applied at each 
extremity. These bones may, however, be fractured more or 
less near their extremities; sometimes even it happens in their ex- 
treme points, as shall be explained in treating of the fractures of 
the neck of the femur and humerus. Sometimes, too, the same 
bone is fractured in different points, whether it be caused by a 
weight falling on a fragment of a single fracture, or whether a 
cause of that nature alone, and exclusively of any pre-existing 
fracture, break the bone into several distinct splinters. This last 
species of fracture, which the ancients termed " nut-like," in 
allusion to the breaking of a nut by a hammer, is distinguished 
by the descriptive name of comminutive fracture. 

The differences relative to the part of the bone fractured, esta- 
blish a distinction of great importance, and not purely scholastic, 
as is imagined by some; for these differences influence the treat- 
ment and prognosis, as shall be proved. Thus, in a fracture of 
the middle part of a bone, though, on account of the bone being 
less thick in that part, and the contiguous surfaces therefore less 
extensive, the fractured portions are more easily and more widely 
separable one from the other, yet this kind of fracture is the 
least dangerous; because, in such cases, the cause is seldom ap- 
plied to the part fractured, and for that reason the surrounding 
soft parts are injured equally seldom. Another reason of this 
difference is, that a less force suffices to break the bone in the 
midt le than in any other part; besides, the means usually em- 
ployed to keep the fractured portions in just contact are more ef- 
fectual, because they are longer. Add to all this, that inflamma- 
tion, stiffness, and anchylosis of the joint, are less likely to hap- 
pen than when the bone is fractured near the articulation. 

With respect to the direction of the fracture, there are several 
distinctions to be made. It is called transverse when its direction 
is perpendicular to the axis of the bone; oblique, when it devi- 
ates from the perpendicular. In this respect also, the comrninu-* 



OF FRACTURES IN GENERAL. 1 3 

live fracture is to be considered as of a particular species. This 
fracture of the bone into several pieces of different directions, is 
always attended with contusion of the surrounding soft parts. 
Another species of fracture of a longitudinal direction has been 
admitted by Duverney> of which he quotes two cases, and com- 
pares it to the cracks which sudden drying causes in a board that 
had been impregnated with humidity. J. L. Petit has, with 
reason, denied the possibility of this species of fracture ; arguing, 
that the cause which could fracture a bone longitudinally would 
fracture it more easily transversely, and must necessarily have 
done so. The cases of these pretended fractures related by Du- 
verney are by no means satisfactory; for it is very difficult to as- 
certain the existence of such a fracture through the skin, perios- 
teum, and intermediate parts. Heister admits its possibility how- 
ever, and even asserts, that the panaris is for the most part ow- 
ing to the longitudinal fracture of the finger-bones; but this er- 
roneous opinion has been amply refuted by Louis at the conclu- 
sion of his discourse on Petifs Treatise on the Diseases of the 
Bones. We adopt the opinion of this latter author, and reject as 
impossible, the longitudinal fracture, unless that name be applied 
to longitudinal splinters of comminutive fracture, as is most like- 
ly to happen when the fracture is occasioned by a gun-shot. 

The most important distinction of fractures is that resulting 
from the different situations of the fractured portions; the know- 
ledge of their derangements is of the greatest importance, be- 
cause the principal object in the treatment of fractures is to pre- 
vent or remedy these derangements. The separation of the frac- 
tured parts is not, however, essential to the disease, for it often 
happens that the leg is fractured without any change in the form 
of the limb; and this is particularly the case when the tibia alone 
is fractured at its superior extremity, because its diameter is con- 
siderable in that part, and the extensive surfaces in contact can- 
not separate without difficulty: the fibula also contributes to re- 
tain the fractured portions in their natural situation. But when 
both bones of the fore-arm or leg are fractured, it rarely happens 
that the derangement of the parts is not the distinctive sign and 
proof of the accident. This derangement attends, almost with- 
out exception, the fracture of the thigh and arm, these members 
being each formed of a single bone, and surrounded by very pow- 
erful muscles. The causes of this derangement, and its varieties, 
shall next be considered. 

It may happen in the direction of the diameter of the bone, be 
parallel to, or form an angle with the axis, or merely affect the 
pircumference. 



14 OF FRACTURES IN GENERAL. 

When a bone is fractured transversely, the contiguous surfaces 
may remain in partial contact, or be totally separated. In a frac- 
ture of the tibia, for instance, the inferior portion of the bone 
may be pushed inward, and totally separated from the superior; 
or the external part of the former may be placed in contact with 
the internal of the latter. This incomplete derangement in 
the direction of the diameter of the bone, does not produce any 
shortening of the limb; but when this derangement is complete, 
then follows that parallel to the axis of the bone. The derange- 
ment in the direction of the diameter happens when the fractu- 
red bone is of a considerable size, as the tibia, for instance, 
and the fracture transverse; and when the proper means of keep- 
ing the parts in their natural situation have been too long neg- 
lected. But if the fracture be oblique, the surfaces not extensive, 
and the accident neglected, the derangement in the direction of 
the axis takes place, and the limb is shortened. In this last-men- 
tioned might be included the fracture of the patella, olecranon, 
and calcaneum; with this difference, however, that in the latter 
cases the fractured ends recede one from the other, and are al- 
ways found separated by a greater or less distance, instead of 
passing one by the other, as in the former case. 

The third species, viz. that in which two fragments form an 
angle one with the other, has not been mentioned by authors, 
and takes place principally in cases of comminutive fracture. It 
might happen, however, in a simple fracture of the leg, as may 
easily be conceived by supposing the foot placed on an inclined 
plane; in which case the angle formed would be salient anterior- 
ly, if the heel were lower than the fore part of the foot, posteri- 
orly if the contrary. 

The fourth species, or that affecting the circumference, is pro- 
duced by the rotation of the inferior fractured portion on the 
superior, in such a manner as that the part which was anterior 
becomes internal or external. We have an instance of this spe- 
cies of derangement in the fracture of the neck of the femur; 
when the foot being ill supported by the apparatus, and obeying 
its weight, aided by that of the leg and by the contraction of the 
muscles, turns outward, and carries the inferior fragment in the 
same direction; in which case, the anterior part of the body of 
the bone corresponds no longer to the anterior part of the neck. 

The bones being but passive instruments of loco-motion, pos- 
sess not, in their own organization, any cause of the change of 
situation which takes place, but yield to exterior causes, to the 
weight of the member, and to muscular contraction; whence it 
appears, that the causes of this change of situation may be very 



Of FRACTURES IN GENERAL. t$ 

Various. The cause of the fracture may also be the cause of the 
derangement of the fractured portions; as when the thigh, for 
instance, is fractured by a fall from some height: if the weight 
of the body, pressing on the inferior extremity which bears on 
the ground, bends the femur forward, the force will not be en- 
tirely spent in producing the fracture, but will, in addition, pro- 
duce a greater or less derangement of the fractured portions. 

The celebrated Ambrose Pare has offered, in his own case, a 
fracture and separation of the bones produced by the same cause. 
This eminent surgeon received a kick from a horse on the leg 5 
with such force, that the lower fractured portion abandoned en- 
tirely the upper, which, impelled by the weight of the body, 
pierced the flesh, integuments, stocking, and gaitre, and drove 
its pointed extremity even into the earth. 

The weight of the limb suffices alone to produce the angular 
derangement, or that affecting the circumference, as has been 
already explained, when treating particularly on that subject. 
Another cause is, the impulse frequently communicated to the 
limb, by the assistants, during the dressing: but of all these cau- 
ses, the most powerful is the contraction of the muscles. 

Of the muscles which surround a fractured bone, some are at- 
tached to that bone in a great part of its length, and therefore in 
many cases to both portions of the fractured bone. Others ex- 
tend from the bone which is superior to that fractured, to that 
which articulates with the lower portion, or to the lower frag- 
ment itself; there are still others which terminate in the upper 
fragment, the other extremity of which may be more or less dis- 
tant. The muscles of the thigh offer examples of these three 
different dispositions. The triceps is attached to the whole length 
of the femur; the biceps, semi-tendinosus, and semi-membrano- 
sus, descend from the pelvis to the leg, to which the lower part 
of the femur is articulated, and all the movements of which it 
obeys-, the great adductor muscle has its insertion in the lower 
part of the femur itself: finally, the psoas, iliacus, pectineus, &c. 
&c. descend from the loins and the pelvis, and have their inser- 
tion near the superior extremity of the femur. 

The muscles which are attached to both portions of the frac- 
tured bone, contribute very little to their change of situation; 
but may, however, draw them both to the side on which they 
are inserted, and thus change the direction of the limb. The 
triceps, and more particularly its middle part, acts thus on the 
fractured femur, and renders the thigh convex anteriorly. The 
brachialis anterior tends to produce the same effect, when the hu- 
merus is fractured below its middle part. But the change from 



l6 OF FRACTURES IN GENERAL. 

the natural situation is principally owing to the muscles which are 
inserted into the lower portion of the fractured bone, or the limb 
with which it articulates. Let us suppose the fracture of the hu- 
merus between its superior extremity and the insertion of the 
great pectoral muscle; this muscle, aided by the latissimus dorsi 
and teres major, draws the inferior portion inward and upward, 
and causes it to ascend on the interior side of the superior, which 
rests motionless on account of its shortness, and because the mus- 
cles, which are inserted into it, are not acted on by any cause 
that excites them to action. In the fracture of the neck of the 
femur, the superior portion of the fractured bone has no muscle 
inserted into it, and remains motionless in the articulating cavity. 
Those muscles which, on the contrary, are attached to the lower 
portion, draw it upward and backward, and render its being dis- 
placed in that direction inevitable. 

The lower portion being acted on by the limb to which it is ar- 
ticulated, follows all its motions, and is liable to be displaced by 
the action of the muscles which are inserted into it. Thus, in 
fractures of the body of the femur, the biceps, semitendinosus, 
and other muscles, draw the leg, and with it the inferior portion, 
upward, inward, and backward, and cause it to ascend on the 
internal, and a little on the posterior side of the superior portion, 
the inferior extremity of which projects, in that case, on the an- 
terior and external side. 

In the fractures of the leg, the gastrocnernii muscles, &c, draw 
the inferior portion upward and backward, with the foot; for in 
this, as in every similar case, the stronger muscles displace the 
lower portion of the fractured bone, and draw it in their direc- 
tion: hence it is, that in this case the portion is drawn backward as 
well as upward, because the muscles are more numerous and 
larger on the back part of the leg than on any other. Therefore, 
when a fracture takes place in any part of a bone, it is easy to de- 
termine, from a knowledge of the muscles, what species of de- 
rangement will follow, if there be no counteracting cause. Fi- 
nally, the muscles which have their insertion in a superior frag- 
ment, may produce its separation from the inferior. "When the 
femur is fractured immediately below the small trochanter, the 
iliac and psoas muscles draw forward the inferior extremity of the 
superior fragment, which raises the skin and projects more or 
less. It is to be observed, however, that the displacing of this 
fragment is very rare, whilst the inferior fragment is displaced in 
almost every case. 

Hitherto we have considered the derangements of fractures as 
simple, but they may be complicated; as for example, when in a 



OF FRACTURES IN GENERAL. 17 

simple fracture of the femur, the lower fragment has ascended 
upward and inward, and the foot being ill supported inclines ex- 
ternally at the same time. The derangement in this case will be 
composed of the four species already described. 

There are other differences still which depend on the fractures 
being simple or compound. A simple fracture is that in which 
the soft parts have received no other injury than that necessarily 
produced by the fracture; for it is easy to conceive, that a frac- 
ture cannot take place without lacerating more or less the perios- 
teum, the small blood-vessels, and the muscular fibres contiguous 
to the fracture; some degree of contusion and of swelling follows 
necessarily, and the skin of the part becomes livid and yellow in 
two or three days. A fracture is compound when it is accompa- 
nied by circumstances which require particular modes of treat- 
ment; such are a much greater degree of contusion than ordi- 
nary; a solution of continuity of the surrounding soft parts, whe- 
ther that be immediately produced by the fracturing cause, or by 
the fragments penetrating through the skin, after having lacerated 
the intermediate soft parts: this happens when the fracture is very 
oblique and the fragments pointed. This compound fracture may 
be rendered still more complex, by the rupture of a large blood- 
vessel, whether an artery or vein, and by the effusion of blood in 
the cellular texture, which would be its necessary consequence. 

Fractures are but rarely accompanied with luxation; in which 
case the luxation must necessarily precede the fracture; for the 
fracture once effected, the fragments are not susceptible of luxa- 
tion: any motion which may be communicated to them can only 
impel them into the surrounding soft parts producing more or less 
laceration. 

Finally, fractures may be accompanied with other morbid af- 
fections, whether pre-existing to the fracture, succeding that ac- 
cident, or operating as its predisposing cause. Thus persons af- 
fected with a fracture, are also often affected at the same time 
with a vitiated state of the solids and humours; such are, for in- 
stance, the scurvy, scrofula, the venereal disease, or cancer. Add 
to all this, that the irritation caused by a fracture may be the occa- 
sion of an acute fever, which generally changes to the reigning 
epidemic. 

We shall not treat here of the distinction of fractures into com- 
plete and incomplete; because these denominations appear to us 
unfounded, and fit only to lead into error. By complete fractures, 
authors mean those in which both bones of a limb are at the same 
time fractured; as those of the leg or fore-arm: incomplete, those 
in which only one of these bones is fractured, the other not being 
3 



1 8 OF THE CAUSES OF FRACTURES. 

injured; but it is evident that in this case the fracture is complete ; 
for to the term incomplete, we can only attach the idea of a bone 
partially fractured, an occurrence utterly impossible. 



SECTION n. 

Of the Causes of Fra&ures. 

The causes of fractures are as various as the means by which? 
that effect may be produced ; and, like the causes of other dis^- 
eases, may be divided into predisposing, and remote. In the 
first class of causes are ranged the situation and functions of the 
bones, the age of the individuals, and their diseases, if affected by 
any. Superficial bones are more easily fractured than those which 
are covered by a considerable depth of soft parts. The functions 
of some bones render them more liable to be fractured than others; 
thus the radius, which supports the hand, and serves in some 
respect as a handle to it, is more liable to be fractured than the 
cubitus. The clavicula, which preserves the shoulder and ster- 
num in their proper position, and supports on its arched extre- 
mity all the motions of the superior extremity, is on that account 
frequently fractured. The gradual accumulation of phosphate of 
lime in the cellular structure of the bones, renders them brittle 
in proportion as we advance in life. In old age the proportion of 
the inorganized to the organized part is so great, that the bones 
are then fractured by the slightest cause. In childhood, on the 
contrary, the fibrous and organized part prevails, and communi- 
cates its properties to the bone, which is then flexible and elastic. 
An advanced period of life is then, to be reckoned as one of the 
predisposing causes of fractures. Certain acrimonies affect the os- 
seous system, by attacking its organized part, and reducing it to 
the same state as- in old age, and render it even still more brittle. 
Thus, women affected with old and ulcerated cancers, have been 
known to fracture their bones, in performing the natural and or- 
dinary motions of the body, or merely in changing their position 
in bed; instances of which are recorded by Louis and Saviard. In 
cases of this nature, all the bones of the body being equally af- 
fected, several fractures happen at the same time, and reduce the 
sufferer to the lowest state of wretchedness. The principal indi- 
cation in such cases is not that of the fracture, as it is only a symp- 
tom of a more dangerous disease, the cure of which ought prin- 
cipally to be attended to. A certain degree of cold has been nun*- 



OF THE CAUSES OF FRACTURES. If 

"ber.ed among the predisposing causes of fracture ; but if this acci- 
dent be more frequent in winter than in summer, it is because 
persons are then more liable to accidents from falling. 

Every efficient cause acts in overcoming the natural cohesion of 
the osseous particles, by separating these particles, and lengthen- 
ing the bone beyond its natural extensibility; the force thus acting, 
may have been applied on the part fractured immediately, or on 
some distant part. When the cause of the fracture is applied to 
both ends of a bone, the bone is curved by the approximation of 
its extremities; thus it is, that, by falling on the shoulder, the 
clavicle, forcibly pressed against the sternum, is curved and frac- 
tured, as if by what the French term contrecoup. In falling on the 
knees, the femur, pressed between the weight of the body and 
the ground, bends about its middle part, and the fracture takes 
place there. In these and similar cases, the natural curvature of 
the bones contributes, with the force applied, to determine the 
fracture in a certain part; and in such cases the contusion is less 
considerable than if the fracture had been produced by a force 
immediately applied to the fractured part ; for the action of the 
fractured extremities on the surrounding soft parts is then the only 
cause of laceration or irritation. But a force which fractures a 
bone exactly on the part which it strikes, bends it to the opposite 
side, and wounds or lacerates the soft parts. Thus a blow of a 
stick on the middle part of the clavicle, where the fleshy parts give 
it but a trifling support, bends it downward and backward, and 
fractures it, but never without producing a greater or less contu^ 
sion, and sometimes a contused wound. If the fracturing force 
strike a bone equally supported in all its parts, the fracture will be 
of the comminutive species, that is, in several fragments: the 
Contusion is always great in such cases. 



SECTION III. 

Of the Signs of FraElures. 

The signs or symptoms of fractures drawn from circumstances, 
and established by reasoning, are never conclusive. The pain, 
for instance, however intense, and the impossibility of moving 
the limb, may be occasioned by a simple contusion, a luxation, and 
a variety of other causes. The immediate signs (the natural evi- 
dence of which precludes reasoning), generally called sensible 
^igns, such, for instance, as an alteration in the form of the limb, 



Q.O OF THE SIGN'S OF FRACTURES. 

its being shortened, and the crepitation produced by the fractu- 
red surfaces in rubbing one against the other, can alone give, any 
certainty of the existence of a fracture. 

When the limb affected is found shorter than the other, it is 
necessary, before pronouncing on the existence of a fracture, to 
be certain that no luxation has taken place, that it is not natural- 
ly so, nor in consequence of a former fracture ill set. In com- 
paring the length of the lower extremities, the body should be 
placed, so as that the anterior and superior processes of the ossa 
ilia may be in a line parallel to the horizon; for if one of them 
be lower than the other, the member of that side will appear 
longer than the other. 

Whoever has acquired a precise knowledge of the natural cast 
and conformation of our members, he more especially who has 
accurately studied the relative situation of the processes on the 
extremities of the bones, will quickly perceive any change indu- 
ced by a fracture. Whenever, in consequence of a blow or a 
fall, a member becomes concave in a part where it is naturally 
convex or straight, and vice versa; this change of form and di- 
rection must be attributed to a fracture, with derangement of the 
fragments. The internal side of the great toe, when the foot 
bears on an horizontal plane, ought to be in the same perpendi- 
cular line with the inside of the patella: nothing but a fracture 
of both bones of the leg can change this relative position of these 
parts. The relative position of the condyles of the humerus, and 
of the apophyses of the olecranon, indicate in like manner the 
luxation or fracture of the humerus. The derangement of the 
fragments may sometimes be perceived by moving the fingers on 
the parts of the bone which are least covered by the integuments. 
This sign is easily detected in the fractures of bones which are 
not surrounded by much flesh, but which lie almost immediately 
under the skin: such, for example, are those of the lower jaw 
and the clavicles. 

But of all the symptoms, crepitation is the most general and 
distinctive; and can never be confounded by an experienced 
practitioner with the noise produced by emphysema, by an aque- 
ous effusion, or the defect of synovia. In order to know if this 
symptom exists, the operator, in some cases, seizes the member 
between both his hands, and presses it in different points of its 
length; it is thus that the fractures of the radius are ascertained, 
by pressing that bone from the external side to the internal. In 
other cases the operator takes a fragment in each hand, and by 
turning their extremities in opposite directions, produces the 
crepitation, if the fracture really exists: if the volume of the 



OF THE SIGNS OF FRACTURES. 21 

member requires it, the operator causes the superior fragment to 
be held by an assistant, whilst he moves the inferior on it, if the 
fracture really exists, as is supposed by the trial, for which reason 
we have used the term fragments, as if it really did exist. 

Although in the greater number of cases it be easy to ascertain 
the existence, or non-existence of a fracture, by the foregoing 
signs; yet there are cases in which certainty is very difficult to be 
obtained. This difficulty may depend on several causes. 

In some eases the bone affected is surrounded by such a depth 
of fleshy parts, that the solution of continuity is almost impossi- 
ble to be ascertained, and the crepitation is very indistinct. If in 
a case of this nature, such, for instance, as in some fractures of the 
neck of the femur, the separation of the fragments one from the 
other be inconsiderable, the fracture may easily remain undisco- 
vered. The fracture of one of the bones of the fore-arm or leg 
is often difficult to be perceived, because the other bone remain- 
ing whole, preserves the form of the member, by preventing 
any considerable separation cf the fragments. 

Finally, if the surgeon be not called in, until a compound frac- 
ture has been still further complicated by an inflammatory swell- 
ing, it will be extremely difficult to ascertain with certainty the 
existence of the fracture; and though that knowledge should be 
obtained, yet it will be prudent to await the abatement of the 
symptoms before any attempt be made to set the fracture. 

When every possible trial has failed, and doubts still remain on 
the existence of a fracture, it will be prudent to apply the ordi- 
nary apparatus imbibed with some resolvent liquid; after the 
lapse of a few days, the apparatus should be taken off, and dis- 
continued if it be found that no fracture exists, or re-applied, in 
the contrary event; at all events, no inconvenience can arise from 
its first application. 



SECTION IV. 

The Prognosis of FraElures 

Is different according to the bone fractured, the part of the 
bone where the fracture has happened, the direction of it, and 
the circumstances which attend it. 

The fracture of bones which are superficial, and but thinly co- 
vered, is, ceteris paribus, less dangerous than the fracture of 
bones surrounded by many and strong muscles. Fractures of the 



22 THE PROGNOSIS OF FRACTURES. 

superior extremities are always less dangerous than those of the 
inferior extremities. The fracture of the middle part of a bone 
is less dangerous than that of its extremities; because in the 
former case it happens frequently, that the cause has not actr 
ed immediately, that the soft parts are not much contused, and 
the inflammatory swelling is less to be apprehended. Fractures 
of the extremities of bones may produce a false anchylosis of the 
neighbouring articulation. It is thus that in the fracture of the 
femur, a little above the condyles, the congestion extends to the 
knee, and occasions a stiffness, which it is difficult to remove : 
if the inflammation extend to the articulation, the consequence 
is still worse. Finally, the splints acting only on one of the 
fragments, render their disjunction very easy. Therefore, the 
fracture of the neck of the femur is more dangerous than that of 
the body of the same bone. With respect to the direction of the 
fracture, those which are transverse are less dangerous than the 
oblique; and the greater the obliquity, the greater the danger, 
as the disjunction is on that account more easy; for which reason, 
a very oblique fracture of the body of the femur is esteemed fully 
as dangerous as that of its neck. 

The accidents which attend a fracture add more or less to its 
danger. In a case of extreme contusion, attendant on a commi- 
nutive fracture, and in which some of the splinters have lacerated 
the part to an excessive degree, the inflammation may be so vio-r 
lent, as that mortification will ensue, and extend from the mem- 
ber to the trunk, and kill the patient in a very few days. In ge- 
neral, fractures complicated with contusion and wound, are more 
dangerous in the inferior than in the superior extremities. 

Finally, the prognosis will be more or less unfavourable, ac- 
cording to the health and age of the individual. In a debilitated 
old man, a fracture is more dangerous, than in a person in the 
flower of youth and health. There are certain dispositions of 
the body, which influence very much the prognosis. Scurvy, 
for instance, retards to such a degree the formation of the callus, 
that, joined with old age, it may prevent it entirely. The state 
of pregnancy, notwithstanding what authors have said of it, does 
not retard the consolidation of a fracture, at least not to any sen- 
sible degree. - 



OF THE TREATMENT OF FRACTURES. 23 

SECTION V. 

Of the Treatment of FraElures. 

The first and principal indication in a fracture, without de- 
rangement of the fragments, is to retain the fragments in their 
natural situation, to prevent the bad symptoms which generally 
follow, or combat them if they have already taken place; but if 
there be derangement, as most generally happens, it will be ne- 
cessary, in the first place, to set the bone, that is, to restore the 
fragments to their natural situation. 

The manner of setting a fractured bone varies, according to 
the nature and species of the fracture; and the precept is not 
perfectly correct, which says, that in every fracture, extension^ 
counter-extension, and coaptation are necessary; because in seve- 
ral cases the extension and counter-extension are perfectly useless? 
as, for instance, in the fractures of the patella and olecranon, in 
which the fragments separate in opposite directions. It is mere- 
ly necessary for their reduction to push the fragments one to- 
wards the other, having first extended the leg or fore-arm, in 
order to relax the muscles which have their insertion in the part 
affected. In the derangement in the direction of the diameter of 
the bone, only a very slight degree of extension will be necessa- 
ry, in order to diminish the friction of the fractured surfaces, 
which move in contrary directions. Extension and counter-ex- 
tension are still useless, when the displaced fragments form an 
angle one with the other; for it will suffice to place the member 
on an horizontal plane, in order to reduce the member to its na- 
tural direction. The derangement of the circumference is alike 
easily reduced by a rotatory motion given to the lower fragment, 
in the direction contrary to that which it took in quitting its na- 
tural situation. 

Extension and counter-extension are not therefore of any very 
evident utility, except in the derangement in the direction of the 
axis of the bone, in which both fragments mutually pass one 
another. 

Extension is the force exerted on the lower fragment, in order 
to bring its superior extremity lower than the inferior extremity 
of the superior fractured portion: counter-extension is a resisting 
force, which prevents the whole limb, or even the body, from 
obeying the force of extension. The hands of intelligent assist- 
ants are always best for both these purposes; it is but very sel- 
dom that any advantage can be derived from the use of mor& 



24 OF THE TREATMENT OF FRACTURES. 

powerful means, which by their excessive force extend too vio- 
lently the muscles and soft parts, occasion much pain, and pro- 
duce spasmodic contraction of the muscles, which resist always 
in proportion to the force of extension, and on that account ren- 
der it most frequently of no effect. 

The practice was formerly to apply the force of extension on 
the inferior fragment, and that of the counter-extension on the 
superior; but exclusive of the difficulty of seizing the two frag- 
ments, which difficulty is in some cases insurmountable, as in the 
fracture of the neck of the femur; there is, besides, a great dis- 
advantage attending it when practicable, namely, the spasmodic 
contraction of the muscles which surround the fracture, caused 
by the irritation and violence which they suffer. 

It is therefore better to make the extension on the lower part of 
the limb, or on the bone which articulates with the inferior frag- 
ment, and the counter-extension or that which articulates with the 
superior. In a fracture of the leg, for instance, the extending force 
should act on the foot, and the counter-extending on the thigh; 
whilst in that of the thigh, these opposing forces should be applied 
to the leg and pelvis. There is nothing to be said as to the degree 
of force to be employed, because that must vary according to the 
extent of the derangement, and the number and strength of the 
muscles which have produced it. The direction in which these 
forces ought to act, is that which the inferior fragment pursued 
in taking its unnatural position; but this applies alone to the force 
of extension, because the opposing force is a mere resistance. 
Thus, if, in a fracture of the thigh, the lower fragment has 
ascended on the internal side of the superior, the foot and knee 
will be turned a little externally; and the extension ought there- 
fore to be directed at first downward, and outwards; afterwards, 
in proportion as the limb recovers its proper direction, the frag- 
ment ought to be drawn into its natural position. The assistants 
employed in this operation should be very intelligent, because, 
when extension is well made, coaptation becomes very easy. It 
is much easier to set a fracture, than to keep the bones in their 
place; in which it differs from luxation, which is difficult to be 
reduced, but easily prevented from relapsing. The means com- 
monly in use to maintain the portions of a fractured bone in exact 
contact, and the member perfectly motionless during the time 
necessary for the formation of the callus, are reducible to a pro- 
per position, repose, bandages, and other kinds of apparatus, 
such as fanons, faux-fanons^ compresses, stuffing, splints, machines 
of various constructions, and the means of effecting perpetual 
extension. We shall consider each of these in detail, successively. 



OF THE TREATMENT OF FRACTURES. 25 

In the first place, a situation is to be given to the limb, in which 
it may continue as long as the affection lasts ; for that purpose it 
ought to be placed on a horizontal plane, so disposed, that the 
intervals between it and certain parts of the limb shall be filled 
up, in order that every part of it may be equally supported. 
This horizontal support ought to be capable of making a conside- 
rable resistance; without, however, being hard enough to give 
any uneasiness or pain. For this purpose a mattress of hair seems 
preferable to any other; because one of wool or feathers yields 
too much to the weight of the limb and apparatus. 

Surgeons were for some time divided in their opinions on the 
best position. Pott has advised the limb to be kept half bent; 
which position, he says, has the advantage of giving to the mus- 
cles which surround an articulation, an equal and moderate de- 
gree of tension; whereas, if the member be placed straight, some 
of these muscles will be much extended, whilst others are as much 
relaxed. The latter position, however, is that which is general- 
ly preferred. 

Demi-flexion is the most natural position; it is that which our 
limbs spontaneously assume during sleep, and has for that reason 
been recommended both by Galen and Hippocrates; but a limb 
half bent, is not solidlv fixed, and changes frequently its situati- 
on, by numerous involuntary motions, which may be occasioned 
by dreams or pain. This position has, besides, this great incon- 
venience, that during the treatment, the length of the fractured 
limb cannot be compared with that of the opposite side, nor can 
it therefore be known if the fracture be well set, and the appara- 
tus well applied; and in truth, demi-flexion becomes at length as 
painful as the extension at full length. The advantages of the 
♦ former have therefore been a little exaggerated by Pott, as well 
as the disadvantages of the latter, which alone is now used in 
France, and generally adopted in foreign countries. 

In whatever position the limb is placed, most perfect repose is 
absolutely necessary, particularly in the commencement; for if 
the fractured pieces be moved one upon the other, nature cannot 
effect their reunion, which would therefore be retarded or total- 
ly prevented, if the friction of the surfaces were frequent, and 
suffered to continue long; in which case an articulation would be 
formed in the situation of the fracture, and consequently the pa- 
tient remain disabled for ever after. 

It is necessary to apply proper bandages and other apparatus, 

without which the position given to the member, however good, 

would be insufficient; because, without these, the involuntary 

motions which are inevitable, those which are produced by pain, 

4 



26 OF THE TREATMENT OF FRACTURES. 

and those again which are rendered necessary by our natural wants, 
would certainly, without that precaution, disturb more or less the 
just relative position of the fractured pieces, which even the de- 
pressions and inequality of the bed would affect, if not guarded 
against. 

Bandages had been for a long time considered as the most ef- 
fectual means of retaining the fragments in just contact; but it is 
easy to prove, that bandages, however contrived, can have but 
little, or absolutely no effect for this purpose. We shall examine 
successively, those which have been in use, viz. the roller, eight- 
een tailed bandage, and that of Scultet, composed of separate 
pieces. 

The first ought to be long enough to cover the whole limb, 
three inches broad, and rolled up in one. It is applied, by draw- 
ing first three folds of it over the fractured parts; it is then made 
to descend to the extremity of the limb, in such a manner, as 
that each roll shall cover a part of the preceding; it is made to 
ascend again in like manner to the situation of the fracture, when 
three folds more of it are applied; after which the superior part 
of the limb is covered, in the same manner as the inferior; and 
if the bandage be long enough, it may be again rolled on down- 
wards. Let us suppose this bandage applied to a fracture of the 
middle part of the femur, or humerus: it is plain that those parts 
of it which are applied on one of the fragments alone, are abso- 
lutely of no effect, and that that part of it only which comprehends 
both fragments, can contribute to keep them in contact. But in 
order to understand how extremely trifling its effect must be, it 
is sufficient to remark, that, as it is but three inches broad, it can 
include only an inch and a half of each fractured portion; and 
that this very trifling power is still farther diminished, by the 
greater or less quantity of soft parts which intercept its action. 

In this respect, the eighteen-tailed bandage is preferable to the 
former. It is composed of three pieces of linen, equal in length to 
the member, and broad enough to pass once and a half round the 
limb. These pieces are sewed together by a seam, which runs from 
one extremity to the other; and afterwards, cut each into three; 
so that the whole is composed of eighteen pieces, nine at each 
end. The bandage thus composed, being moistened, is extend- 
ed under the limb, and the middle piece on each side is first ap- 
plied on the situation of the fracture, then the superior ones, 
and afterwards the inferior, and so successively with the middle 
and inferior pieces. The six middle pieces of this bandage act 
with more efficacy on the fracture, than the folds of the former 
bandage; because being much broader, they encompass a greater 



OF THE TREATMENT OF FRACTURES. T] 

part of it. It has this other advantage over the former bandage, 
that its application is easier, and does not require that the limb 
should be kept raised, nor exposed to many motions, which are 
always hurtful. 

Scultet's bandage is composed of as many pieces of three in- 
ches broad each, as are necessary to cover the whole length of 
the member, in lapping two thirds over one another. It is com- 
posed of a piece of linen, of three times the length of the 
limb, and broad enough to pass once and a half round the limb; 
it is to be cut according to its breadth, in pieces of three inches 
broad each: this done, the pieces are extended under the mem- 
ber, one covering three parts of the other in proceeding from 
the inferior part. This bandage like the two former, acts only 
by the pieces which encompass at once the contiguous parts of 
the two fragments; it is preferable however in the following re- 
spects. 

It contributes as much as the others to maintain the fragments 
in their just position; it compresses sufficiently the member, and 
prevents any oedema; it is in this respect preferable to the 
eighteen-tailed bandage, the parts of which not passing one on 
the other, do not compress all the parts equally; whence it hap- 
pens, that those parts which correspond to the edges of the 
pieces become ©edematous. 

This bandage can be taken off, and re-applied, without mo- 
ving the limb, in which it is far preferable to the first mentioned 
bandage, the disadvantage of which in that respect has been al- 
ready pointed out. The eighteen-tailed bandage cannot be so 
conveniently renewed as that of Scultet, because, when any part 
of it is soiled by purulent matter, or any other cause, it is neces- 
sary to remove it entirely, and apply another; whereas any par- 
ticular piece of that of Scultet may be changed, and a new one 
applied in its place, which may be done without moving the 
member, by fastening the new one to the extremity of the old, and 
drawing it into its proper situation at the same time that this latter 
is taken away. It ought, therefore, to be preferred to the two 
former, except in cases of simple fracture of the superior ex- 
tremities. 

Although bandages may be of no great use for keeping the 
broken pieces in their proper position, yet they are useful for 
supporting topical applications, and preventing oedema of the 
limb; they are still further useful in benumbing the muscles, and 
in preventing their contraction. 

The faux-fanon is a cloth rolled on itself, and differs from the 
fanon in this, that in the latter there is enclosed a piece of wood. 



28 OF THE TREATMENT OF FRACTURES 

They are applied on the internal and external sides of the limb; 
but our limbs, like the fawns, being nearly round, these latter 
come in contact with the limb but by a very narrow surface, so 
that in tightening the strings by which they are secured, they are 
liable to slide forward or backward; in which cases their action is 
frustrated, no effect produced, and the fractured portions sepa- 
rate without any difficulty. 

Splints are much surer means; they may be formed of different 
substances, and their shape and length accommodated to those of 
the limb in which the fracture has taken place. 

Splints made of pasteboard were formerly in use, which being 
wet were easily adapted to the form of the member, and in dry- 
ing were moulded to it. They have been also made of the bark 
of trees, but the brittleness of these caused them to be laid aside. 
At present, wood or tin are the only materials of which splints 
are made: they are usually thin and narrow, and rounded at 
their extremities: their length must be determined by circum- 
stances. Those of tin are extremely proper for simple fractures 
of the superior extremities; their flexibility admitting them to be 
adapted exactly to the form of the member. In case of not ha- 
ving them, their want may be supplied by thin laths of flexible 
wood, susceptible of being moulded into the shape of a trough. 
In general, splints for the superior extremities ought to equal the 
fractured bone in length. In fractures of the arm, the splint 
which is placed on the fore part, ought to be a little shortened, 
and not to descend to the bend of the arm, in order that its de- 
mi-flexion may not be prevented. 

The splints designed for the inferior extremities ought to be 
strong, thick and flexible, and longer than the member. For a 
fracture of the thigh, the external splint ought to extend from 
the superior part of she os ilium, to a little lower than the sole of 
the foot; the internal should equally descend from the upper and 
internal part of the thigh to a little below the foot, and the an- 
terior from the groin to the superior part of the leg. In frac- 
tures of the leg, the internal and external splints ought to ascend 
above the knee, and descend below the foot. 

In order to understand how the splints act, it is necessary to 
recollect what has already been saicl of the derangement of frag- 
ments; it is clear they prevent that in the direction of the dia- 
meter of the bone, by being in opposition one to the other, 
on every side of the bone, and by resisting therefore any force 
which might tend to move either fragment internally or exter- 
nally, .forward or backward. In fractures of the inferior extre- 



OF THE TREATMENT OF FRACTURES. 2$ 

mity, no posterior splint is necessary, because its place is supplied 
by the plane on which the member rests. 

Splints prevent also the angular derangement of the fragments, 
by supporting each of them in the whole length of the member. 
They prevent also the derangement in the circumference; but in 
order to do so, they must aft on that part of the limb which is 
articulated with the lower fragment. For in a fracture of the 
femur, for instance, if the splints do not descend below the thigh 
there is nothing to prevent the weight of the foot or leg, or that 
of tjie bed-cloaths, from turning them either inward or outward, 
and with them the lower fragment. 

The derangement in these three last mentioned directions is 
more easily prevented by splints, than that in the direction of the 
axis, or by chevauchement. If the fracture be transverse, the 
splints prevent even this latter kind of derangement, because 
they obviate that in the direction of the diameter of the bone, 
which must necessarily precede it. But, if the fracture be ob- 
lique, that is, with sloped surfaces, the fragments do not then 
Oppose a sufficient mutual resistance, but slide on one another 
with a facility proportional to the obliquity of the fracture. 

In such a case, the splints can oppose the derangement only by 
the degree of compression which they make on the whole length 
pf each fractured portion; but if the fracture be very oblique, the 
surfaces smooth, and the part surrounded by strong muscles, this 
derangement will probably take place. Thus it is found by expe- 
rience to be almost impossible to maintain properly adjusted, an 
oblique fracture of the body of the femur, by the aid of splints 
alone. It is equally difficult to remedy by their means oblique 
fractures of the clavicle; because they cannot be applied on every 
side of that bone. 

The impossibility of obtaining, in certain eases, a cure exempt 
from all deformity, by ordinary means, has made surgeons recur 
to another apparatus, which, by drawing continually the two pie- 
ces in opposite directions, prevents them from repassing one on 
the ofher, and keeps the fractured surfaces in just contact all the 
time necessary for their consolidation ; this method has been 
termed perpetual extension. 

This apparatus should not be applied before the irritation and 
spasm of the muscles are completely removed. It prevents the 
muscular fibres from being too forcibly stretched or elongated be- 
yond their natural extensibility ; it supplies the place of the bone, 
which, before the fracture, regulated the contraction of the 



30 OF THE TREATMENT OF FRACTURES* 

muscles. Its application may be submitted to some general rules, 
which I shall copy here from a work on that subject.* 



RULE I. 

To apply the extending Force on the Parts of the Members inferior 
and superior to the fratlured Bone. 

The extending and counter-extending forces ought not to be 
applied immediately on the fractured bone, but on that which 
articulates with the inferior fragment, for the extension; and 
for counter-extension, on that which articulates with the superior. 
Continued extension not differing from simple extension and 
counter-extension, except in its being continued, the same rea- 
soning applies to both cases. 



RULE II. 

To acl on as great a Superfcies as possible. 

In order to fulfil this condition, the bandages and other pieces 
of the apparatus, ought to be as broad as possible. The effect 
which external causes have on our bodies, is small in proportion 
to the extent of the surfaces on which they act; because the ac- 
tion is then supported by a greater number of parts. A thin and 
narrow bandage of linen folds on itself quickly, and becomes a 
hard cord, which causes a distension of the vessels of the inferior 
part of the member, by obstructing the return of the lymph and 
venous blood. 



RULE III. 

To give to the extending Power a Direclion parallel to the Axis of 

the Bone. 

The science of mechanics teaches us that the action of a force 
on a lever is decomposed, if its direction be oblique to the lever, 



* Anatomico-surgical Dissertation on Fra&ures of the Neck of the Femur, by 
A. Richerand, octavo, Paris, year 7. 



OF THE TREATMENT OF FRACTURES. 3 1 

one part of it acting in that direction, and the other in that of the 
lever; that is, in geometrical terms, the force acting on the lever 
will be to the whole force as the angle, formed by its direction 
with the lever, is to a right angle. It is easy to perceive that the 
part of this force which is not employed to effect the desired pur- 
pose, must counteract the proposed end, by causing pain, and 
uselessly compressing the parts. 



RULE IV. 

The Extension ought to be as gradual as possible, operating slowly, 
and by Degrees. 

Animal parts which yield to long continued and insensible ac- 
tion of exterior causes, resist any violent and sudden effort, and 
revolt against it, as it were, with all their force: thus the slower 
and the less rapid the extension, the more easily do the parts of 
our body yield. 

Continued extension does not exclude the ordinary apparatus, 
but is additional to it. 

As every part of the surface of our limbs does not lie in the 
same plane, that is, as our limbs are prominent in some parts, and 
depressed in others, and therefore liable to be hurt and bruised 
by hard, straight, and inflexible splints, even to the degree of 
producing gangrene, some means of remedying these disadvan- 
tages, and preventing these bad effects, were naturally recurred 
to. For this purpose the different depressions of the limb are 
filled with lint, rags of old linen, compresses, or, what is still 
better, with little bags of the chaff of oats; the facility, which 
these latter offer, of moving the chaff from one part to another, 
as well as their soft and equable pressure, give them an evident 
advantage: by these means the pressure becomes equal on every 
part of the length of the member. Finally it is not superfluous 
to remark, that tape ought to be preferred to strips of linen, 
which knot with difficulty, particularly when wet, for the pur- 
pose of binding externally the whole apparatus. The number 
of these tape strings must be proportioned to the length of the 
member; as must the length of the bags of chaff to that of the 
splints, the action of which they are intended to moderate. 

We shall in the next place examine what is required by the 
third indication of fracture? that is, to prevent the complications 
which may succeed to it, and to remedy them when they have 
really taken place. 



32 OF THE TREATMENT OF FRACTURES. 

In every fracture, with the exception of those of the superior 
extremities, which are simple, the patient ought to be confined 
to a low regimen for the first four or five days: more or less blood 
should be drawn, if it be not contra-indicated by extreme old age, 
or great debility. No greasy irritating plasters, of which quacks 
make so much use, such for instance, as the plaster of Cyroane, 
are to be employed; but in their stead, it will be sufficient mere- 
ly to cover the limb with several folds of compresses soaked in 
camphorated spirit, or a solution of the acetate of lead, or any 
other repellent liquid, with which also the other parts of the 
bandage should be moistened. A solution of common salt is to 
be avoided, because that salt would quickly crystallize, hardening 
thereby the different pieces of the bandage, and giving them a 
stiffness unpleasant to the patient. The bowels should be kept 
open by gentle laxatives; such as veal broth, whey acidulated 
with tamarinds, &c. When the lapse of a few days renders this 
regimen no longer necessary, the patient should be allowed a mo- 
derate quantity of very nutritive and easily digestible food; for it 
would be not only useless, but dangerous to prolong the low regi- 
men, in the ease of a simple fracture, which does not sensibly 
disturb the functions, and which requires for its consolidation, a 
degree of vital energy in the solids, which a too sparing diet would 
enfeeble. 

We shall not here amuse our readers with the different means 
recommended to increase the viscidity of the blood, in order 
thereby to accelerate the consolidation of the fracture; but pro- 
ceed to consider the treatment adapted to compound fractures: 
this treatment must vary according to the nature of the compli- 
cation. 

Under this head, we have to consider, in the first place, the 
very difficult, but also very rare case of fracture accompanied 
by luxation. When this takes place, the luxation must have pre- 
ceded the fracture; for a bone once fractured, is no longer capa- 
ble of luxation. The principal question is, to which of the acci- 
dents shall we in the first place direct our attention ? Some are of 
opinion, that the dislocated fragment should be first replaced in 
its natural articulation ; others, on the contrary, recommend to 
await the consolidation of the fracture, before any attempt be 
made to remedy the luxation : but we adopt, most decidedly, the 
first opinion; for during the treatment of the fracture, the soft 
parts acquire a stiffness, and become so habituated, if the expres- 
sion may be allowed, to their new situation, that the dislocation 
cannot, without great difficulty, be remedied ; but if in order to 
effect it, violent efforts and straining are unavoidable, it will in 



OF THE TREATMENT Of FRACTURES, 23 

that case be better to set the fracture first ; and as soon as the con- 
solidation is a little advanced, habituate the member to certain 
gentle motions, in order to preserve the suppleness of the liga- 
ments, which will facilitate the cure of the dislocation, when the 
complete consolidation of the fracture allows it to be attempted. 

When the soft parts of a fractured limb are violently contused, 
but without external wound, the apparatus should not be too 
much braced; and Scultet's bandage should in such cases be al- 
ways used, even though the fracture be in the superior extremity. 
A large portion of blood should be immediately drawn, and the 
blood-letting repeated, except the patient has the stomach full, 
as is generally the case in hospitals; for the common people are 
usually brought there in a state of intoxication. The bandages 
must be taken off on the following day; this rule is without ex- 
ception; the neglect of it has caused a mortification of the limb, 
which takes place by the bandages becoming too tight, in conse- 
quence of the swelling "which ensues, and by the consequent 
stoppage of the circulation. On this first removal of the banda- 
ges, the member is generally found hard, tumefied, tense, and 
the patient complains of great pain. In which case the fractured 
part is to be covered with emollient poultices, over which the 
proper bandage may be applied, and the splints moderately braced» 
In cases of extreme contusion* without a wound of the integu- 
ments, the tension and inflammatory swelling may become so in- 
tense, as to cause the cuticle to rise in little blister-like vesicles 
filled with a limpid serum, very different from that blackish serum 
which fills the vesicles attendant on mortification. These vesi- 
cles should be opened without detaching the cuticle, and the 
small openings covered with linen on which some cerate has been 
spread. By these simple means the surgeon has the satisfaction 
of seeing the inflammation, and all its menacing consequences, 
subside in a few days, leaving merely a slight degree of ecchymo- 
sis, which disappears in a short time. The poultices are then 
discontinued, the patient is allowed a nourishing diet, the splints 
are braced to the ordinary degree, and the treatment is after- 
Wards the same as that of a simple fra£ture. 

If a vessel of a certain magnitude is opened by a fracture, and 
the cellular texture of the limb becomes distended by the effused 
blood, which may be perceived by the tumefaction, and black or 
livid colour of the member, the surgeon ought, without hesita- 
tion, to make an incision in the part over the artery, and apply on 
it two ligatures, one above the other, below the wounded part. 
J. L. Petit relates a case of a false primative aneurism, produced 
by the laceration of the anterior tibial artery in a fracture of the 



34 ©F THE TREATMENT OF FRACTURES*. 

leg. It is possible too, that the laceration of a vein may occasion 
an effusion of blood, easy to be mistaken for a false primitive 
aneurism. Such, probably, was the case of the female of Gros 
Caillou, who fractured her leg with a wound by falling from her 
cart. In three or four days after entering the hospital De la, 
Charite, the leg swelled enormously, the skin became of a vio- 
lent colour, and of a marbled appearance; and there issued from 
the wound but a small quantity of blood. The lesion of the an- 
terior tibial artery was suspected ; the taking of it up was not, 
however, attempted: the patient was bled, emollient poultices 
were applied, and by these simple means the tension quickly di- 
minished, and the effusion and distension vanished; a considera- 
ble degree of ecchymosis, however, remained, which gradually 
disappeared. 

The wounds which render a fracture compound may be owing 
to the cause of the fracture, or may be occasioned by the penetra- 
tion of the point of one of the fragments though the integuments. 
In the latter case, the wound should be enlarged by a bold inci- 
sion, and the projecting fragment pushed into its proper situation. 
But if the projecting part be of a considerable length; if the mus- 
cles contract spasmodically, and much exertion and straining be 
necessary to reduce it, it would be better, in such a case, to cut 
off a portion of the projecting bone, which would facilitate its 
reduction, and prevent an excessive laceration of the parts. A 
young man having the thigh fractured, with a projection of two 
inches of the superior fragment stripped of its periosteum, was 
well for two days after the forced reduction of this portion, with- 
out having any part of it cut off; but on the third day the limb 
became violently inflamed,, the tension and tumefaction extreme,,, 
mortification quickly followed, gained rapidly on the trunk, and 
put an end to the patient's existence. When the fracture has 
been reduced, as has been directed, without too violent exer- 
tions, the wound is generally treated as a simple division of the 
integuments. Copious and repeated blood-letting obviates the 
inflammatory symptoms so much to be apprehended. 

When the wound is produced by the same cause as the fracture,- 
such, for instance as the wheel of a very heavy carriage, which 
causes much contusion, the nature and method of the treatment 
must vary according to the circumstances of the case. If the 
lesion be excessive, the soft parts torn, enormously contused* 
and almost totally disorganized, the able and experienced prac- 
titioner sees at the first glance if the member be inevitably lost, 
or if mortification be certain: in which case he resolves instantly 
on amputating, and prevents by this conduct, the mischief which 



OF THE TREATMENT OF FRACTURES. 35 

might ensue from the gangrene, the extent of which might prove 
"fatal. It is true, that in many cases in which the loss of the 
member was deemed inevitable, patients have preserved it by 
their own obstinacy. We ought not however, on that account, 
to follow the example of Van Swieten, who drawing a general 
rule from a single fact, establishes it as a maxim, that amputation 
should never be immediately performed after a fracture. In sup- 
port of this doctrine, he cites a case of comminutive fracture, in 
which amputation was decided on, but the patient was deterred, 
or would not submit to it. La Motte treated the patient as in less 
extraordinary cases: he extracted several splinters, opened some 
abscesses, and succeeded finally in effecting a recovery, without 
the loss of the limb; but not, however, without having experi- 
enced a great number of disagreeable occurrences, of which this 
surgeon has given the particulars. It is impossible to establish 
any general rule for eases of this kind. The surgeon must be 
directed by his own talents and sagacity in each particular case. 

In most cases, if the injury be not very great, the fracture 
may be set, and the splinters, which are entirely separated from 
.the bone and from the soft parts, may be extracted; the wound 
is then gently dressed, the bandage of Scultet is applied, and the 
splints are but very slightly braced. The patient is restricted to 
the severest regimen, and copiously bled: a degree of inflamma- 
tion equal to the extent of the evil is to be expected. If, on the 
third or fourth day, the tension become extreme, the part cold 
and livid, with vesicles arising on it, gangrene is certain. It is 
then necessary to wait until the progress of the gangrene is ar- 
rested, which, however, may be anticipated by the antiphlogistic 
regimen, and by making incisions to favour the separation. As 
soon as the mortification is stopped, and a red inflamed circle 
marks the boundary between the sound parts and those mortified, 
it is necessary to amputate; for if the putrid sanies be absorbed 
into the system, it will produce slow fever and death. 

If the inflammatory swelling terminate by suppuration, as 
most generally happens, it is apt to be very abundant. When 
suppuration has commenced, the emollient poultices are discon- 
tinued. The dressings are repeated as often as maybe necessary, 
to prevent the pus from retarding the consolidation by stagnating 
on the surfaces of the broken portions. The strength of the pa- 
tient should be supported by the most nourishing diet, and by 
tonic medicines, such as the extract of bark, &c. 

By this treatment it generally happens that in about a month 
.the suppuration diminishes, the lips of the wound begin to close, 
and the consolidation of the fracture advances; but a greater or 



$6 OF THE FORMATION OF CALLUS. 

less deformity is inevitable, from the impossibility of bracing suf* 
ficiently the apparatus. In some cases, the suppuration conti- 
nues, and the fragments, always immersed in pus, cannot reunite*, 
the pus is absorbed, and the patient dies of the marasmus, to 
which diarrhoea and colliquative sweats reduce him. In order 
to prevent this fatal termination, it is necessary to amputate as 
soon as it is perceived that the suppuration cannot be stopped. 
Delay in this case wouki be very dangerous. 

It appears, therefore from the principles which we have esta- 
blished, that comminutive fracture, always attended with much 
disorder of the parts, offers three distinct cases in which ampu- 
tation is necessary: 

First, When the disorder and disorganization is such as to ren- 
der 'gangrene inevitable. 

Secondly, When gangrene takes place in opposition to the well 
directed use of antiphlogistic remedies. 

Thirdly, When the too abundant suppuration prevents the con- 
solidation of the fracture, and induces debility and hectic fever. 



SECTION VI. 

Of the Formation of Callus, 

All that art can do in any fracture, is to maintain the frag- 
ments in contact*, their reunion and identification is the work of 
nature alone: The different opinions on the mode in which this 
is effected, are as follow: 

The ancients attributed it to the effusion of what they called the 
osseous juice, a fluid capable of growing hard, and contracting strong 
adhesions with each of the fragments, by which means it was suppo- 
sed to join them together, as two pieces of wood are united by glue. 
The moderns who have adopted this opinion of the ancients, 
have said that this ossifiable humour was furnished by the vessels 
of the bone and surrounding parts, these vessels being developed 
by the inflammatory state.* An English surgeon-j- has compared 
this secretion to that of pus in the inflammation of soft parts. 
But in allowing the existence of this osseous juice or humour, 
which, by the bye, is mere supposition (for the ancients did not 
understand by it either the gluten extracted from bones by means 

* See the Memoirs of Hailer and Bordenave, colle&ed by Faugeroux. 
•f Essays on Frattures and Luxations, by John Aitkin. London, 1790. 



OF THE FORMATION OF CALLUS. 37 

of ebullition in Papin's digester, nor the phosphate of lime, which 
fills the cells formed by this gelatinous matter;) yet would it re- 
main to be proved how the thickening or concretion of this fluid 
could constitute solid organized matter. By being effused be- 
tween the fragments, this inorganized fluid should naturally in- 
tercept or dam up the medullary canal; but that does not take 
place, as any one may be convinced, by splitting a bone which 
had been fractured and re-consolidated. Finally, this osseous hu- 
mour should naturally, by its effusion, create tumours of greater 
or less magnitude in the neighbourhood of the fracture. 

And, in fact, the deformity which attends a great number of 
fractures treated without method, has been attributed to the de- 
fective or superabundant effusion of this matter. Thus, say the 
advocates of this opinion, the fracture of the clavicle is always 
attended with more or less deformity, because the particular po- 
sition of that bone does not admit the application of a bandage, 
which, as in other eases, might prevent a redundant effusion of 
the osseous juice. The opinion of Duverney was different;' he 
thought that the irregular formation of the callus was owing not 
to any want or defect of bandage, but to the bone's being strip- 
ped of its periosteum, and wanting, #terefore, the means of gi- 
ving to the callus its just conformation. But at present it is known 
beyond all doubt, that this irregularity of form is to be ascribed 
to the ill setting of the fracture. 

When the phenomena of the production of callus were ob- 
served with more care, a more natural explanation of this opera- 
tion was attempted. 

Duhamel attributed it to the periosteum, which he considered 
also as the organ of ossification. When a bone is fractured (says 
that great naturalist), the periosteum of the two fragments unites 
first; afterwards this membrane swells, and forms a kind of 
hoop around the fracture. The periosteum thus tumefied, im- 
bibes the humours, softens, and becomes a kind of jelly, which 
passes quickly to the state of cartilage. Vessels are formed in 
this cartilaginous substance; and nuclei of bone originate in se- 
veral points, and gradually unite; and when the part of the pe- 
riosteum adjoining the fracture is thus united, it has the appear- 
ance of a ring, which comprehends each of the fragments, and 
keeps them united. It was immediately objected to Duhamel, 
that in splitting a bone lengthwise, both fragments were found 
united, and not in simple contact, like two pieces of wood held 
together by a ring, agreeably to his theory. In order to answer 
this objection, he supposes that the periosteum extends itself 
from the circumference to the centre or the bone, and that this 



2% OP THE FORMATION OF CALLUS. 

elongated part of it underwent a process similar to that of the 
parts contiguous to the fracture, and thus identified the two 
pieces. 

The intimate adhesion of the periosteum to the bone, and its 
inextensibility, caused some doubts on this elongation; besides, 
did it really take place, the medullary canal would in consequence 
be obstructed. This theory has, for these reasons, been almost 
universally abandoned, and has at present but few partizans. 

When there happens a solution of continuity of the soft parts 
of our bodies, if the lips of the wound be not brought into im- 
mediate contact, the vessels become turgid, the vascular tissue 
extends forwards, and gives rise to those small red conical tu- 
mours known by the name of granulations. This augmentation 
in the calibre of the vessels, and a certain degree of inflamma- 
tion in the granulations which arise from them, are means which 
nature employs to effect the reunion of divided parts. But it is 
not known, whether or not, in this case, the iibres of one side 
become continuations of those of the other; if the vessels iden- 
tify in like manner by anastomosing; or if an humour of a cer- 
tain nature be effused between the divided parts, which it agglu- 
tinates together. The only thing certainly known on this subject 
is, that the cicatrix is organized, as has been proved by incontest- 
able experiments. 

There is a strict analogy between what takes place in the solu- 
tion of continuity of soft and osseous parts. The irritation cau- 
sed by the fracture produces the extension and turgescence of 
the vessels of the periosteum, of those of the bone itself, and of 
those of the medullary membrane ; and then the only condition 
necessary to consolidation is that the fractured surfaces be pla- 
ced in just contact. But this operation of nature, by which an 
organized substance is produced, is slower in bones than in soft 
parts, which are furnished with numerous vessels, and in which 
the vital properties are not impeded, as m the bones^ by the de- 
position of a saline inorganized matter. In examining a bone ha- 
ving a consolidated fracture, the place of the consolidation is 
marked merely by a line; and if the bone be split, the medulla- 
ry canal is found narrowed at that part, and in some cases totally- 
obstructed. 

The production of granulations on the membrane which lines 
the bone, accounts for this narrowing or obstruction of the me- 
dullary canal, one or other of which takes place, according to 
.the greater or less activity of the vessels of that part. This the- 
ory, suggested by the striking analogy between the fleshy and 
osseous parts, supported by observation of the phenomena of the 



OF THE FORMATION OF CALLUS. 29 

generation of callus in animals, has this further advantage over 
all the others, that it stands uncontroverted by any fact: on the 
contrary, it is confirmed by all the facts hitherto observed. Thus 
k offers a very natural and easy explanation of the difference of 
time required for the formation of callus in youth and old age, 
by the different proportions of the phosphate of lime which the 
bones contain at these periods. 

The generation of callus is then an operation perfectly analo- 
gous to the cicatrization of wounded soft parts: its being more 
tardy is owing to the difference in the activity of the vital prin- 
ciple in these, and in bony parts. During a few days immedi- 
ately subsequent to a fracture, the inflammation exists only in the 
neighbouring soft parts, and the bone seems perfectly inert; but 
its texture is soon after perceived to soften in that part, and the 
fractured surfaces become covered with granulations produced by 
the enlargement of the blood-vessels. This, growth takes place 
without any secretion of pus, and the consolidation is effected by 
a process as little understood as that of cicatrization. Instead of 
pus, the enlarged vessels secrete and deposit a calcareous phos- 
phate, which gives a solidity equal to that of the rest of the bone. 

But leaving to physiologists the task of explaining the forma- 
tion of callus, let us consider what more particularly interests us, 
that is, the means of accelerating, retarding, or totally prevent- 
ing it. These means or causes are either general or local: we 
shall proceed to consider both the one and the other in detail. 

The callus is formed, ceteris paribus, with more promptitude 
and facility in infancy and youth than in the adult or in old age* 
The younger the individual, the greater the proportion of the 
gelatinous to the calcareous part of the bones, and the more ra- 
pid on that account is. the organization. 

When the individual is extremely old, the vital principle be- 
comes extinct, as it were, by the accumulation of calcareous phos- 
phate, the enlargement of the vessels cannot take place, and con- 
sequently the consolidation, particularly if to old age be joined a 
vitiated state of the fluids, such as the scurvy, cancer, &c. can- 
not be effected: these diseases alone suffice in many cases to pro- 
duce the same effect. A strong robust man of the sanguine tem- 
perament, recovers much more rapidly from a fracture than a 
weak person, or one affected with a cachexy. The difference of 
sex causes no difference in the generation of callus. At the pe- 
riod, however, of the cessation of the menses in our climate, 
that is, from the forty-fifth to the fiftieth year, its generation is 
slower, and the cure of fractures of women of that age is subject 
to the same irregularities as their other diseases. 



40 OF THE FORMATION OF CALLUS. 

The state of pregnancy does not perceptibly retard the genera- 
tion of callus, though Fabrice de Hilden wishes to form a conclu- 
sion to the contrary from the observation of a few facts. 

However favourable the general disposition may be to the quick 
consolidation of a fracture, different local circumstances may re- 
tard it. If one of the fractured portions does not receive a suf- 
ficient quantity of blood to nourish it, and to maintain in it the 
necessary vital force, the vessels will not be enlarged, nor, of con- 
sequence, the fracture consolidated. An instance of this is seen 
in fractures of the neck of the femur, in which the head of that 
bone is completely separated from its body, and the ligament 
which performed the functions of periosteum, and which envelo- 
ped the neck, is torn; so that the only vessels that enter the part 
of the bone thus detached, are those that pass to it by the round 
ligament; which cannot in old age, when these vessels are nearly 
obliterated, furnish a sufficient quantity* of blood for the genera- 
tion of callus. It is necessary, then, that both fractured portions 
be endued with a certain vital energy, without which it would be 
as useless to attempt their union, as that of a gun-shot wound be- 
fore the parts disorganized by the violent contusion, be separated 
from the sound parts by suppuration. 

Another local condition favourable to the formation of callus 
is, that the surfaces of the fractured portions be brought precise- 
ly into contact. Let us suppose, for example, a transverse frac- 
ture of the femur, and that the fragments, after sliding one npcn 
the other, have fallen into the derangement in the length of the 
bone, the fractured portions cannot, in this case, touch one ano- 
ther without the periosteum intervening. Inflammation will be 
extremely slow; and even at the end of two months the progress 
in the formation of callus will be scarcely perceptible. To effect, 
in this case, a complete cure, even with a shortening of the mem- 
ber, will be extremely difficult. It is therefore absolutely neces- 
sarv to maintain the fractured portions in the position in which 
they have been set, as already prescribed. 

The perfect immobility of the fractured portions is not less es- 
sential to their union, than their proper contact and vitality. If 
the fragments were moved every day, no progress towards a union 
could be made; or were there fleshy granulations already formed, 
jthey would be quickly obliterated by the friction, and the surfa- 
ces would become smooth and polished. The periosteum and 
cellular texture, distended and thickened, would form a kind of 
orbicular ligament round the ends of the fractured portions, and 
an unnatural articulation would be formed, which would render 
the member absolutely useless. 



OF THE FORMATION OF CALLUS. 41 

When the usual period of consolidation is past, the apparatus 
Ought to be taken off, and the limb examined, to see if the frac- 
tured portions have continued in the situation in which they were 
placed, and if the whole limb constitute but one piece. The 
time necessary for reunion depends on several circumstances, of 
which the principal are, the age of the patient, and the kind of 
bone fractured. In general, fractures of the bones of the supe- 
rior extremities are consolidated in a shorter time than those of 
the inferior. Thus we frequently see a fracture of the clavicle 
in adults consolidated in thirty days, and that of the radius and 
cubitus in nearly the same interval; that of the humerus in from, 
about thirty-five to forty days; whereas those of the leg and thigh 
require generally from forty to fifty days. A vulgar prejudice 
exists on this subject among the lower order of persons, who are 
those usually brought into hospitals: they think that every frac- 
ture ought to be consolidated in forty days exactly. But it is im- 
possible to predict what time may be necessary for this purpose. 
In an infant, consolidation will take place six or eight days soon- 
er than in an adult; and in an old man eight or ten days later. 

If, on raising the apparatus, the limb be swelled, or a tumour 
be observed in the situation of the fracture, in consequence of 
the ends of the fractured portions having passed one another; 
and if, at the same time, the member, more or less shortened, 
be moveable in that part, it will be evident that the fracture is 
not consolidated, and that the apparatus has not had its due ef- 
fect, whether from being badly applied, or not sufficiently exa- 
mined from time to time. 

If, instead of this swelling, the pieces be found moveable one 
on the other, and separated by a small interval, and the member 
has not diminished in length, the want of consolidation proceeds, 
in this case, either from the patient's advanced age, a vicious 
state of the fluids and solids, or from some imprudent motions 
of the limb during the treatment. In this latter case, if the 
fracture has already been of some months standing, the contigu- 
ous extremities of the fragments are worn into a rounded form 
by the friction, and surrounded by a species of ligament formed 
of condensed cellular membrane, so that an unnatural articula- 
tion is formed at this place. 

Finally, it is possible, that on taking off the apparatus, the 
fracture may be found not to have consolidated, but with a 
shortening and deformity of the limb. In this case it will be re- 
quisite to adopt the following proceedings. 

If the ends of the fractured portions pass one another, or if 
the fractured surfaces are partially in contact, or totally separated, 
6 



42 OF THE FORMATION OF CALLUS*. 

it will be necessary to reset the fracture, and to employ continue 
ed extension, if the ordinary means be insufficient for maintain- 
ing the fragments in their just relative situation. The duration 
of this second treatment is at least as long as that of the first-, 
for if the natural period of consolidation be once past, the frac- 
tured surfaces are no longer equally disposed to unite. 

If the fractured portions continue very moveable one on the 
other, notwithstanding the just position has been preserved, and 
if the, cause of this be the advanced age of the patient, the same 
apparatus should be reapplied, and the vigour of the patient in- 
creased by the well directed use of wine and nourishing diet. 
By persevering in these means a cure is at length effected in the 
space of five or six months. But if some constitutional disease, 
such as cancer, scurvy, &c. be suspected of being the cause of 
non-consolidation, these diseases must be combatted by appro- 
priate remedies, the mechanical means persevered in, and every 
kind of motion of the limb abstained from. 

But whether the fractured portions have passed one another, 
or whether an articulation has been formed between the fractured 
surfaces, if the fracture has been already of several months du- 
ration, the action of the fractured surfaces ought to be revived 
by rubbing them forcibly one against the Other, in order to ex- 
cite the degree of inflammation necessary for the generation of 
callus. The fractured ends of the bones having by these means 
acquired a disposition favourable to their agglutination, the ap- 
paratus should be reapplied, the extension continued, if neces- 
sary, and the treatment prolonged until the cure be complete. 

If, notwithstanding these means, the pieces do not unite, 
there remains another and last resource, the cutting off of their 
extremities. This operation is painful, terrifying, and of dubious 
event; its success has, however, been frequent enough to war- 
rant the trial. It would be impracticable in fractures of the leg 
and fore-arm, on account of the difficulty of separating from the 
integuments the two bones of which each of these parts is form- 
ed, and on account of the numerous nerves and arteries which 
would be in danger of being wounded by the large incisions ne- 
cessary for this operation. It is therefore practicable only in the 
femur and humerus, especially the latter. 

This operation is performed by making a longitudinal incision 
over the fracture, on that side of the limb where the bone is 
most prominent and least covered; the nerves and vessels are to 
be avoided with the utmost care; each end of the fractured por- 
tions is nicely laid bare, and made to project beyond the soft 
parts, which may be protected by compresses, or by a thin plate 



OF THE FORMATION OF CALLUS. 43 

jof lead or pasteboard, from the action of the saw with which a 
sufficient quantity of each fragment is- to be taken off. This part 
.of the operation being performed, the extremities of the fractured 
portions are restored to the position which they ought to have, 
and the wound dressed with soft lint, in short, the subsequent 
treatment is the same as that already prescribed in the case of 
compound fracture; that is, Scultet's bandage is to be applied 
moderately tight, as well as the splints and other parts of the 
apparatus; for beyond all doubt a violent inflammation and copi- 
ous suppuration will succeed. An abundant formation of puru- 
lent matter is disadvantageous, on account of the pus stagnating 
in the bottom of the wound, lubricating the fractured surfaces^ 
and preventing their agglutination,, 

Citizen Boyer has performed this operation but once; and al- 
though he was not successful, I think it my duty to mention the 
,case. 

A man, aged thirty-six, had his right arm fractured, and no- 
thing was done to adjust the fractured bone. The solution of con- 
tinuity took place above the middle part of the humerus: this arm 
had been for so long a time useless to the patient, that he was 
.determined to undergo any trial for effecting a cure, but would 
not listen to . any proposal of amputation. This operation was 
then resolved on: an incision was made over the fracture on the 
external side of the arm, a little above the place where the radial 
nerve winds pn the humerus, for the purpose of saving this 
nerve, and thus preserving from paralysis the posterior muscles 
of the fore arm: this incision being made, he exposed the end of 
.the inferior fragment, and caused it to project by raising the el- 
bow and pushing it inward. 

The soft parts were protected by means of a plate of wood, 
and the conical or rounded part of the ends of the bone was then 
sawed off. The part of the operation for the superior portions 
was more difficult; for the conical part was longer and the point 
sharper: one of the collateral arteries was opened, on which a 
ligature was applied. The end being sawed off, as in the former 
case, and with the same precautions, and both fractured portions 
being restored to their natural direction, it was found that they 
were separated one from the other by an interval of two inches 
and an half. In order to bring them into contact, the elbow was 
raised by means of two casts of a bandage, drawn from the fore- 
arm bent to the shoulder of the opposite side. For the two first 
.days immediately after the operation, no bad symptom took 
.place. The inflammatory swelling and tension, as well as the 
fevqr, were such as might be expected from the extent of tkf 



44 OF THE FORMATION OF CALLUS. 

wound. But on the third day the fever became more violent; 
a redness, and quickly after an erysipelas, appeared on the arm 
of the opposite side; the inflammation extended to the shoulder, 
and afterwards to the fractured arm. The tension was extreme; 
instead of pus there flowed from the wound a bloody sanies; 
gangrene came on, and the patient died on the sixth day. 

The cure obtained by this operation is necessarily attended 
with a shortening of the member; but this inconvenience is but 
slight with respect to the arm: in the thigh it is evident that 
more or less lameness is necessarily the consequence of it. 

It cannot be denied but that this operation is one of the most 
difficult in surgery; but it ought not to be renounced for that 
reason, when any hope may be had of recovering by it the use 
of a disabled member, and when the patient wishes at all risks 
to make the experiment. But should the patient prefer ampu- 
tation to this cruel and uncertain chance, that operation ought to 
be recurred to, when all the other resources of our art have been 
tried in vain. 

The progress of the callus to perfect consolidation is, analo- 
gously to that of the osseous system in general, slow and gradual. 
The patient is not, therefore, to be allowed the free use of a 
fractured limb immediately after the reunion of the fracture. In 
fractures of the inferior extremities, crutches ought to be used 
for some time, and the limb which had been fractured charged 
with its share of the weight of the body, but by little and little. 
From not paying sufficient attention to this circumstance, the 
callus has been sometimes so much pressed, as that the limb was 
shortened, and consequently lameness induced. Besides, the 
slightest false step might cause a relapse of the fracture; for, not- 
withstanding what certain authors have said to the contrary, the 
consolidated part of a fractured bone is never stronger than the 
other parts, nor even equally strong, until after a considerable 
lapse of time. 

To procure the reunion of the fragments without any shortening 
of the limb, is not the sole object to be attended to in the treat- 
ment of a fracture. During the time that the member is neces- 
sarily motionless, the muscles lose the habit of motion, and grow 
rigid, and a false anchylosis frequently follows. This conse- 
quence is particularly to be apprehended in fractures which take 
place near the articulations (as has been already mentioned), in 
those, for instance, of the patella, of the inferior extremity of 
the lemur, of the olecranon, or of the condyles of the humerus. 
It most frequently takes place in the articulations of the knee, el- 
bow and instep. It may be prevented by gently moving the limb 



OF THE FORMATION OF CALLUS. 45 

from time to time, as soon as the consolidation is so far advanced 
as that its progress cannot be retarded by these motions. Finally, a 
false anchylosis may be removed by general bathing, by the use 
of the shower-bath, by resolvent plasters, and by continued and 
gentle efforts, as shall be more fully detailed in treating of that 
affection. 

As fractures of the skull are more important by the necessarily 
attendant affection of the brain than by the simple consideration 
of the fracture, we think it most methodical to refer them to 
wounds of the head. The same may be said of the greater part 
of the fractures of the bones of the upper jaw, the parts of which 
being strongly united together, and to the bones of the skull, 
render them susceptible only of comminutive fracture, when the 
fractured part is that on which the cause has immediately acted. 

Let us suppose that the wheel of a carriage rolls over a per- 
son's head (of which the examples are but too frequent), and that 
the zygomatic arch is thereby fractured; in such a case the sur- 
geon's duty would be merely to bleed the patient, and use other 
means to combat the inflammatory symptoms. It would not be 
prudent to make an incision into the depression of the temple, in 
order to raise the zygomatic arch, at the risk of opening the tem- 
poral superficial artery, and of causing much pain by the lacera- 
tion of the nerves, except in the case that the fractured bone 
crushed into the crotaphyte muscle, should excite great pain and 
other bad consequences. 

If in a fracture of the superior maxillary bones, there should 
be detached from the body of one of these bones, a part of the 
alveolar process with one or more teeth, as in the third case of Le- 
dran's Surgical Observations, it would be necessary to follow the 
example of this surgeon; viz. to fasten silk threads to the teeth 
of the broken portion, which adheres still by the gum, and by 
the internal membrane of the mouth; and then to attach these 
threads to the teeth of the adjacent sound part, the fragment be- 
ing first placed in its natural situation. Dentists frequently em- 
ploy this mean for the purpose of fastening artificial teeth; and 
its use has been advised in cases of fracture of the lower jaw. 
We shall give the details of the fractures of this last-mentioned 
bone, after having first treated of those of the bones of the nose; 
these being in this respect the only bones of the face which me- 
rit particular consideration. 



tf 



CHAPTER II. 



OF THE FRACTURES OF THE BONES OF THE NOSE, 

THESE symmetrical bones, with the ascending processes of 
the maxillary bones by which they are supported, form a 
kind of arch. As they project in the middle of the face, and are 
but slightly covered by soft parts, they are much exposed to dif- 
ferent kinds of fracture from different causes. 

In all these cases the cause of the fracture is always applied to 
that part immediately where the solution of continuity takes place, 
and the fracture may be oblique, longitudinal, or transverse, 
without derangement of the fragments; but it more frequently 
happens that the bones are splintered and crushed into the cavity 
of the nostril; that the nose loses its natural form, and that the 
neighbouring soft parts are much bruised by being crushed be- 
tween the bones and the cause of the fracture, whether a body 
against which the nose has been forcibly struck, or one which 
may have been strongly impelled against it. 

If the soft parts have suffered no solution of continuity, and 
if the fragments have not been displaced, the fracture may not be 
-discovered, because the form of the nose does not change. An 
oversight in this case is not dangerous, as the use of emollients and 
resolvents is all that is required. If the fracture be comminutive, 
not only the inflammatory symptoms ought to be combatted by 
blood-letting and other antiphlogistic means, but further, the 
fragments ought to be replaced, as they strain and irritate the 
soft parts, already contused, by their unnatural situation. For 
that purpose the operator takes a grooved sound, a female cathe- 
ter, a ringhandled forceps, or any such instrument, introduces it 
into the nostrils, and by using it as a lever, pushes the fragments 
outward; at the same time with the index of the left hand applied 
to the ridge of the nose, he prevents them from being pushed out 
too far, and from lacerating the integuments. Sometimes the 
bones continue in the situation in which they have been thus 
placed; but it may happen, that, from being much fractured, and 
badly supported by the soft parts, they fall again inwards; in 
which case a canula of elastic gum should be directed along th$ 



OF THE FRACTURES OF THE BONES OF THE NOSE* 4? 

inferior surface of each nostril, which ought then to be stuffed 
with lint, and gently thrust in, lest the pituitary membrane should 
be hurt. 

In cases of eomminutive fracture, with depression of the splin- 
ters, it would be imprudent to wait the disappearance of the in- 
flammatory symptoms, before making an attempt to raise and ad- 
just the fragments-, because, during the interval, the portions of 
bone might reunite in an unnatural situation, and produce de- 
formity of the nose. 

Fracture of the nasal bones is sometimes attended with very 
dangerous symptoms, whether produced by a violent commotion 
given to the head by the cause of the fracture, or by a co- exist- 
ing fracture of the bones of the skull; or, as some authors think, 
by the concussion communicated to the perpendicular part of the 
ethmoidal bone, and thence to its cribriform part, which would, 
in that case, be fractured, on account of its great tenuity. The 
laceration of the dura mater and its vessels, caused by the fracture 
of the cribriform lamella of the ethmoidal bone, would produce 
effusion, and thus give rise to all the symptoms. It is certain 
that cases have occurred where blows on the root of the nose have 
produced coma, convulsions, and death; particularly when the 
nasal bones were not fractured. How such an injury may take 
place may be easily conceived by the consideration of the effect of 
contre-coup, commotion, and other consequences which may en- 
sue, if a great part of the percussive force be not consumed in 
producing the fracture. 

This etiology is, however, applicable but to persons advanced in 
age, because in youth the perpendicular part of the ethmoidal 
bone articulates with only a very small part of the nasal bones; 
the rest of these bones being then supported by the cartilage 
which separates the nostrils, and with which that part of the eth- 
moidal bone is connected. At this last mentioned period, the 
nasal processes of the os frontis are their principal support, and 
ought therefore to receive the principal part of the concussion. 



48 



CHAPTER III. 



OF THE FRACTURES OF THE LOWER JAW. 

THE great mobility of this bone is the reason of its being 
seldom fractured. A violent blow may however fracture it, 
and wound at the same time, more or less, the neighbouring soft 
parts. It may also be fractured by the passage of the wheel of 
a carriage across it. An impelled force which fractures this bone 
tends first to increase the elliptic curve which is its natural form, 
and that in proportion as it acts nearer to, or farther from the 
angle of that bone ; so that if a succession can be admitted in the 
rupture of the fibres, the rupture ought to commence in those 
which are external. When on the contrary, the solution of con- 
tinuity is the effect of a force immediately and directly applied 
on the part that breaks, there is no tendency to increase the na- 
tural curve, but that part is pushed inward, and the solution of 
continuity commences on the inside. 

These fractures vary, first, as to the part of the bone fractured. 
That sometimes takes place near the chin, but seldom so as to pro- 
duce the division of the symphysis of that part, though it be not 
impossible. At other times the fracture takes place more or less 
near the angle of the bone. Two fractures may occur in it at the 
same time, by which it would be divided into three pieces, of 
which, that corresponding to the chin is extremely difficult to 
manage; because many of the muscles which draw the lower jaw 
downwards, are attached to that part. 

The lower jaw is subject to be fractured, not only near the 
symphysis, but also near the processes which terminate its branch- 
es; that is, near the condyles and the coronoid processes. Of 
these two parts, the condyle is that which is the more frequently 
fractured, it being covered merely by the parotid gland; the co- 
ronoid process being, on the contrary, protected by the temporal 
muscle, by the masseter and by the zygomatic process. 

The fractures of the lower jaw may vary infinitely in their di- 
rections: be perpendicular to its basis, oblique, or longitudinal: 
of this latter, examples have been seen, in which a portion of the 



Of THE FRACTURES OF THE LOWER JAW. 49 

alveolar part, with the teeth implanted in it, was detached from 
the rest of the bone. 

These fractures are seldom simple, particularly if the fracturing 
cause has been directly applied. The soft parts are always more 
or less contused or wounded. J. L. Petit mentions an instance of 
the complete denudation of the cOronoid process, in a case of 
fracture by a kick from a horse. 

In order to form a clear idea of the different ways in which the 
fractured portions of the lower jaw may be deranged, it is neces- 
sary to take a brief view of the muscles by which that bone is 
moved. The temporal muscle having its convergent fibres col- 
lected into one parcel, descends from the temporal to the Zygo- 
matic fossa, and embraces with its inferior angle the coronoid 
process of the lower jaw, of which it is the principal elevator. 
The masseter descends from the zygomatic arch to the external 
side of the branch of the lower jaw. The pterygoideus internus 
descends obliquely backward to the internal side of the same an- 
gle: this muscle serves not only to raise the lower jaw, but also 
to move it a little forward. This last motion is however, especi- 
ally performed by the pterygoideus externus, which, passing ob- 
liquely outward and backward, embraces the neck, or narrowed 
part which supports the condyle. 

The muscles which draw down the lower jaw, are attached to 
the body of that bone, and especially to the process at the chin. 
The greater part of these muscles come from the os hyoides. 
Those attached to it are the platysma myoides, the digastrici, the 
mylo-hyoidei, the genio-hyomei, and the genio glossi. 

Let us see in the next place, how these different muscles con- 
tribute to produce the derangement of the fractured portions. If 
the fracture be near the symphysis, on which is the processus in- 
nominatus, that side to which this process belongs, is drawn 
downward and backward by the submaxillary muscles,' and even 
by those which extend from the clavicle and sternum, to the os 
hyoides, while the other fragment is supported by the levator 
muscles; if the fracture be more backward toward the branches, 
the derangement takes place in the same manner, but with a lit- 
tle more difficulty. In the double fractures, the middle portion is 
perpetually drawn downward and backward by the muscles which 
are attached to the process at the chin, whilst the two lateral are 
supported by the levator-muscles. 

If the branch be the part fractured, any considerable degree 

of derangement is prevented by the masseter which is attached 

to each of the fractured portions. If the neck of the condyle be 

, 7 

1 



5<D OF THE FRACTURES OF THE LOWER JAW. 

the part fractured, the condyle will be drawn forward by th^ 
action of the pterygoideus externus. 

All these different derangements, except the last, take place 
in the same line as that which passes from the teeth to the basis 
of the bone. The fractured portions are never deranged so as 
that one passes on the other, or in the direction of their length; 
for the action of none of the muscles of the lower jaw is parallel 
to the axis of that bone: besides, its extremities are retained in 
the glenoidal cavities of the temporal bones. 

When a blow is received on the lower jaw, or the bone is in- 
jured by a fall on that part, or by the pressure of some heavy bo- 
dy, and at the same time an acute pain is felt in the part; and 
when, with these circumstances, an inequality is found at the ba- 
sis of that bone by moving the fingers along it; when some of 
the teeth, corresponding to that inequality, are found to have 
lost their level, one being lower than the other; and when, be- 
sides, by seizing these apparently deranged parts, one in each 
hand, and impelling them in opposite directions, a mobility and 
crepitation are perceived, there can be no doubt as to the exist- 
ence of a fracture; although there be no denudation of the bone 
by wound, nor any laceration of the gums; circumstances, how- 
ever, which would render the fracture still more evident. 

The fractures of the branches and condyles are not so easily 
distinguished as those of the body of the bone. Yet the acute 
pain which the patient feels in the region of the ear, especially 
v- m he moves the jaw, the crepitation produced by these mo- 
tions, or by pressure on the condyle, are sufficient evidence of 
its existence; if an inflammatory swelling has not taken place be- 
fore the surgeon has been called in. In that case, the diagnosis 
cannot be established, until, by the lapse of a few days, by bleed- 
ing, poultices, and reg^ en, the tumour has been dissipated. 

Fracture of the lower jaw is in general not very dangerous. 
When simple, it would get well spontaneously ; but there would 
be, it is true, some deformity, which it is the surgeon's duty to 
prevent. 

. Compound fractures of the lower jaw are more dangerous; and 
if the nerve which goes to the teeth, be torn, which rarely hap- 
pens, because the greater part of these fractures take place between 
the symphysis and the foramen by which this nerve comes out 
from the conduit through which it runs in the substance of the 
bone, the square and triangular muscles of the chin are paralysed. 
The skin of that part and the internal membrane of the under 
lip preserve their sensibility, which it appears they owe to some 



OF THE FRACTURES OF THE LOWER JAW. J I 

threads of the portio dura of the seventh pair; but the paralysis 
of these muscles does not prove of itself that the jaw is fractured 

In order to set a fracture simple or double of the lower jaw, it 
suffices to push the deranged part upward and a little forward, and 
afterwards, by pressing on the basis of the bone, to bring it ex- 
actly on a level with the portion which has preserved its natural 
position; which may be done by bringing all the teeth of the 
lower jaw into close contact with those of the upper. But the 
facility of setting this fracture is more than counterbalanced by 
the difficulty of maintaining it set. Different means of accom- 
plishing this purpose have been proposed; but those alone act ef- 
ficaciously which keep both jaws together, by supporting the lower 
jaw, and keeping it applied to the superior or upper jaw. 

All other means would be useless, if the jaw were not kept per- 
fectly motionless. And this immobility is extremely difficult to 
be obtained, on account of the motions induced by mastication, 
deglutition, and speech; but which ought to be suspended for a 
time. For the two or three first days the patient should be re- 
strained to a very small quantity of food and nourished afterwards 
with broths, which may be given by introducing a small spoon 
between the teeth a little separated. If he should happen to 
•want a tooth, that will be a fortunate circumstance on this occa- 
sion, because broths may be given through the opening by 
means of a canula, without causing the least motion to the frac- 
tured bone. If the patient be unmanageable, and insist on eat- 
ing or speaking, in opposition to the surgeon's advice, the forma- 
tion of the callus will be slow, and the cure difficult, and inevi- 
tably attended with deformity. An opening might also be pre- 
served by introducing two pieces of cork, one on each side be- 
tween the teeth. 

It has been proposed to tie the two pieces together by means of 
a gold or silver wire, passed from some of the teeth on one side 
of the fracture, to those adjacent on the other side. But exclu- 
sively of this being very difficult, and even impossible in persons 
who have the teeth very close set, the wire could only prevent the 
longitudinal derangement. But we have already shewn that the 
fractured portions have no tendency to derangement in that direc- 
tion, and consequently, that this expedient could be of use cnly 
in case of a part of the alveolar process being detached from the 
rest of the bone. 

Some practitioners have made use of a pasteboard mould, com- 
posed of a semicircular piece, excavated for the purpose of recei- 
ving the neck: This piece is placed horizontally, with its convex 
edge projecting a little beyond the basis of the lower jaw. Ano- 



<2 OF THE FRACTURES OF THE LOWER JAW* 

the? -piece, of about an inch in breadth, is placed so as to extend 
from one angle of the jaw bone to the other, having its under 
edge corresponding to the outer edge of the other, and its upper 
edge on a level with the under lip. Both these pieces are moi- 
stened with a resolvent liquid, which renders them flexible and 
more easily adapted to the form of the jaw. On these pieces are 
placed compresses, also moistened with a resolvent liquid, and a 
chin bandage is applied over all. Although the pasteboard, on 
being dry, constitutes a kind of mould, in which the lower jaw 
is contained, yet as it acts on the fracture only as it is acted on by 
the bandages, and as it injures by its hardness the soft parts 
on which it presses, it has been abandoned. 

If the fracture be pimple, the operator will commence by ap- 
plying two bands externally, of three fingers breadth each: one 
of these is to be passed under the chin, and fastened on the top 
of the head to the patient's cap; the other is to be applied imme- 
diately to the chin and jaw, and fastened at the occiput; after 
which the chin bandage is applied: this bandage must be so long 
as that the two ends of it may cross on the top of the head, and 
broad enough to extend from the lip to the middle point between 
the chin and the neck. The extremities of this bandage are split 
to near the middle part, in which a hole is made to receive the 
chin, and two ends are knotted on the top of the head, and the 
other two on the occiput. For greater security, two bandages of 
this construction might be applied; but if the patient be perverse, 
and the fracture double, it will be necessary to apply the double 
chevestre, which is more easily done than described. 

Fracture of the condyles requires the following modification of 
the apparatus. As that process is incessantly drawn forward by 
the pterygoideus externus, it would be necessary to push it back; 
but being so short, and situated so deeply it cannot be acted on 
but with great difficulty; for which reason the lower portion must, 
if possible, be pushed into contact with the condyle, which may 
be done by making the chevestre act on the angle, and aiding its 
action by means of a thick and graduated compress placed on that 
angle. It is almost needless to remark, that if both condyles be 
fractured, the double chevestre ought to be employed : in this 
case the parts are with difficulty kept in their situation; the ap- 
paratus ought therefore to be often examined, and reapplied fre- 
quently. 

It is particularly important in fractures of the condyles to ob= 
tain a cure without deformity, because the motion of the bone 
would be affected by any deformity that would remain. If the. 



OF THE FRACTURES OF THE LOWER JAW. 53 

patient insists on eating or speaking during the treatment, it is 
probable that there will be no reunion, that the condyle will ex- 
foliate, and be cast out through a fistulous opening. Thus a cart- 
er, who quitted the hospital De la Charite, after being three 
months a patient in it, but without being perfectly cured of a 
double fracture of the lower jaw, one near the middle part, the 
other near the right condyle, returned after an absence of seven 
or eight months to Citizen Boyer, who extracted from a fistula, 
in the external conduit of the ear, a bony mass, which had evi- 
dently the form of the condyle. 

When at the end of fifteen or twenty days, the pieces begin 
to unite, soft food may be given to the patient, instead of broths; 
and according as the solidity augments, the consistence of the 
food may be increased. The cure will be complete between the 
thirtieth and thirty-fifth day, if nothing interrupts its natural 
progress. 

After what we have already said on compound fractures, in 
treating of fractures in general, it is unnecessary to repeat here 
particularly what is there related, and which may be so easily 
applied to the fracture of the lower jaw, attended with vio- 
lent contusion, or a division of the soft parts covering it. It 
may be remembered, however, that this bone frequently exfoli- 
ates, when the fracture is accompanied with a wound, and that 
the cure is on that account much more tedious. 



54 



CHAPTER IV. 



OF THE FRACTURES OF THE VERTEBRAE. 

THE bones which compose the spine are seldom fractured, 
because, like other short bones, they resist any violence 
that might be applied to them, by the equality of their three di- 
mensions. If any great force be applied to the vertebral column, 
it is apter to lacerate the intervertebral cartilages, or to separate, 
them from the vertebrae, than to fracture these bones: they may 
however, be fractured in the very part against which the force 
has been immediately applied. The spinal processes which pro- 
ject from the body of the bones is the part most liable to be frac- 
tured, because it is that which is weakest and the most superfici- 
ally situated. But it seldom happens that the fracture is limited 
to a single vertebra; several of them are generally fractured at 
once, and the spinal marrow suffers at the same time a commo- 
tion or contusion to a greater or less degree: and much less dan- 
ger is to be apprehended from the fracture, than from the. lesion 
of that substance. In fa<t, every cause that will fracture the ver- 
tebrae, must give a commotion to the spinal marrow. 

It is thus that this substance suffers from a fall on the back 
from an elevated situation, or from the action of a bullet, which 
strikes against the vertebrae after having penetrated through the 
soft parts: the displaced pieces of the fractured bones might in 
such cases press on that substance, or the fractured splinters might 
penetrate into it after having pierced the dura mater and its other 
tunics. The laceration of its vessels might also produce an effu- 
sion, which by its pressure would, as effectually as any other 
cause, produce a paralysis of the organs whose nerves proceed 
from the parts of the spinal marrow below the fracture. 

The variety of causes which may give rise to symptoms analo- 
gous to those of fracture of the vertebrae, render it difficult to 
establish a diagnosis. Yet, when a person has fallen on his back 
from an elevated situation, or when a body very forcibly impel- 
led, as a bullet discharged from a musket, has struck that part, 
if a fracture has taken place, some derangement of the spinal 
process of the fractured vertebra may be observed, by an atten- 



OF THE FRACTURES OF THE VERTEBRAE. 55 

tive examination of the part affected. Much pain is caused by 
pressing on that process; the inferior extremities are paralysed, 
as also the rectum and bladder; the patient is afflicted with a re- 
tention of urine and feces, or with an involuntary discharge of 
the latter. 

A sack of flour, weighing 300 lbs. fell on the back of the neck 
of a porter of the corn-hall, in a moment that he was off his 
guard, and laid him prostrate. He complained of a very acute 
pain in the neck; and on being conveyed to La Gharite> it was 
found that the spinal process of the seventh vertebra of the neck 
was more prominent than it naturally is. The superior and infe- 
rior extremities were paralytic, respiration became difficult, the 
bladder and rectum ceased to perform their functions, and the 
patient was suddenly cut off. On opening the body, a fracture 
of the seventh vertebra was found, with derangement of a frag- 
ment which compressed the spinal marrow . 

The three following cases, of which the two first, like the 
foregoing, have been observed at La Charite, prove that the 
commotion or violent distention of the spine can produce the same 
symptoms as a fracture of the vertebrae. 

A hosier fell into a shallow ditch on his loins; the commotion 
was sufficient to produce a paralysis of the inferior extremities. 
After his death, which followed from the fall, no disorganization 
could be perceived, nor any effusion either in tjie cranium or 
vertebral canal. 

A builder fell from a height of fourteen feet, and remained 
for sometime senseless; and, on recovering from that situation, 
found that he had lost the use of his inferior extremities. He had 
at the same time a retention of urine, an involuntary discharge 
of the fseces, and some disorder in the function of respiration. 
Death followed on the twelfth day after the accident; the body 
was opened, and the vertebral canal was found to contain a san- 
guineous serum, the quantity of which was sufficient to fill a lit- 
tle more than its lower half. 

A man excercising himself at feats of activity, distended so 
much the intervertebral ligaments, that he was instantly seized 
with an acute pain in the part so distended, by the strained pos- 
ture which he had assumed: the next day, the inferior extremi- 
ties, the bladder, and rectum, were paralytic, and the patient 
died in a few weeks. 

This paralysis of the inferior extremities, the necessary con- 
comitant of fracture of the vertebrae, and of any lesion of the 
medulla spinalis, is not, in itself, a mortal affection; but the pa- 
tient, losing the power of loco-motion, and being obliged to lie 



$6 OF THE FRACTURES OF THE VERTEBRA. 

perpetually on his back, soon feels a troublesome itching in th^ 
region of the sacrum, on which the pressure of the body is prin- 
cipally concentrated; the skin of this part becomes inflamed, and 
gangrene ensues to a greater or less degree, because the pressure 
on that part intercepts the course of the humours. The bone is 
quickly denuded, the ulcer extends rapidly, and consumes the- 
patient's strength; the dissolution is accelerated by the retention 
of the excrements from the paralysis of the rectum and bladder. 
The catheter, which must be introduced into this latter organ for 
the purpose of evacuating the urine, gives admission to the air; 
its mucous secretion becomes more abundant, and its substance 
thickened ; a slimy matter flows out with the urine, and the pe- 
nis and scrotum become cedematous, &c. A slow fever succeeds 
these symptoms; and the patient, however robust he maybe, falls 
in a few weeks. We have known, however, a man of a very vi 
gorous constitution, to have survived for six months an accident 
of this nature. Examples of recovery are recorded, but they are 
extremely rare, and to be ascribed to the secret operations of 
nature, rather than to the efforts of art; and we repeat, that 
scarcely one in thirty recovers. Almost all die from the ex- 
haustion of their strengh, by slow fever, colliquative diarrhcea, &c. 

Any attempt at setting these fractures, would be not only use- 
less, but dangerous, by the straining which it would occasion. 
General treatment alone can be had recourse to; the inflamma- 
tion and obstruction of the part affected may be moderated by 
cupping and scarification. 

If the patient be affected with a flatulent distension of the ab- 
domen, vomiting, hiccup, and other symptoms of that nature, 
the abdomen may be rubbed with a solution of two drachms of 
camphire, in a sufficient quantity of oil; purgative clysters may 
be also given, and antispasmodic medicines. A catheter should 
be allowed to remain in the bladder, with its external orifice 
corked, in order that the patient's bed may not be wet: the ul- 
cerations of the sacrum are to be dressed simply with pieces of 
linen covered with cerate. If the gangrenous eschar comes off 3 
styrax ointment ought to be applied; and if the patient be fortu- 
nate enough to recover the use of the bladder, rectum, and in- 
ferior extremities, this return of the natural forces may be aided 
by frictions with tincture of cantharides, on the course of the 
nerves of the paralytic organs; and as soon as the patient is able 
to ride, or even walk with the aid of crutches, he will find it 
beneficial to drink the sulphureous waters of Bourbon cr Bare- 
ges. 



OF THE FRACTURES OF THE STERNUM. $J 

Such is the treatment in cases of fracture of the spine. 
Some authors recommend trepanning or cutting out a portion 
of the fractured bone, when the compression of the spinal 
marrqw by effused fluid, or its disorganization by the action of 
a splinter, is suspected ; but exclusively of the difficulty of that 
operation, on account of the great depth of the intermediate 
soft parts, the indication is never sufficiently evident to autho- 
rise it. 

If a fracture of the vertebrae, or an affection of the spinal 
marrow, take place in the neck, death follows rapidly. This 
effect is instantaneous, if the lesion be as high as the origin of 
the cervical nerves, which convey nervous energy to the dia- 
phragm-, for that organ being for the most part supplied by 
these nerves, is deprived of the power of motion, by any 
considerable lesion of them. 

The lesion of the fourth and fifth cervical pair of nerves by 
fracture, supposes that accident to have taken place in the 
third vertebra; because the vertebral nerves originate a little 
higher than the hole by which they pass out of the vertebral 
canal. 



CHAPTER V. 



OF THE FRACTURES OF THE STERNUM. 

THE position of this bone, supported laterally by the flex- 
ible cartilages of the ribs, the great number of pieces of 
which it consists, unless in old age, its thickness, and spongy 
texture, co-operate in securing it against fractures. It may, 
however, be fractured, and in two different ways. The frac- 
ture takes place generally on the part where the force is imme- 
diately applied; but it may be occasioned by an extention, ope- 
rating on both extremities of the bone. 

David has cited (from a memoir on contrecoups, published 
under the name of Basile, among the prize essays of the aca- 
demy) the case of a mason, who, in falling from a great height, 
struck against a cross-bar which intercepted his fall; and on 
8 



58 OF THE FRACTURES OF THE STERNUM. 

which the trunk was so extended, that the sternum was rup- 
tured transversely by the violent action of the abdominal and 
the sterno-cleido mastoidei muscles. In cases of this nature, 
very rare it is true, the fracture must be simple, and without 
derangement of the fragments, or affection of the soft parts. 
But in those produced by the immediate action of an external 
cause, the soft parts are necessarily affected, and the fractured 
portions may be impelled into the mediastinum, and cellular 
texture, so as to wound the pericardium, heart, or lungs. 

Solutions of continuity of the sternum, like those of the 
cranium, are attended with a greater or less effusion of blood, 
mingled with a medullary substance, which is very abundant 
in the sternum; but the consequences of this effusion are very 
different in the two cases. The slightest effusion within the 
cranium, gives rise to the most alarming symptoms, and causes 
sometimes the death of the patient; but in this case, on the 
contrary, however abundant that effusion may be, it seldom 
occasions dangerous symptoms. The heart and lungs being 
composed of a substance less delicate and less compressible than 
the brain, suffer little or no inconvenience from this effusion: 
besides, the capacity of the thorax is variable, and may on 
that account accommodate itself to an unusual quantity of 
fluid. 

A simple fracture is ascertained by the mobility of the 
pieces: that which is compounded with contusion, wound, ef- 
fusion of blood, or by the splinters being thrust inward, is 
easily known by simple inspection of the part. 

A simple fracture of the sternum requires no other treat- 
ment than the application of compresses, repose, and a proper 
position, that is, on the back, with the head and pelvis raised; 
so that the muscles already mentioned, which are attached to 
its extremities, may be in a relaxed state. But in cases (which 
are much more frequent) of fracture, with contusion, wound, 
or penetration of splinters into the mediastinum, the patient 
should be bled, and confined to a low regimen; poultices 
should be applied; and the necessary incisions made for ex- 
tracting the splinters from the mediastinum, or for giving issue 
to the effused fluids. It is but very seldom necessary to tre- 
pan the sternum for either of these purposes; and that opera- 
tion becomes necessary only, when that part of the sternum 
which has been denuded, becomes affected with caries, the fis- 
tula proceeding from which would be incurable by any other 
means. Then a transverse or crucial incision should be 



OF THE FRACTURES OF THE RIBS. 59 

made on the part where the probe points out the course of the 
fistula. The part affected ought to be laid entirely bare, and 
completely removed, by a single or repeated application of the 
instrument, according as it happens to be more or less exten- 
sive. The instrument ought to be precisely the same as that 
used for the head, and applied with all possible care, lest, by 
pressing on it too much, it should be driven into the thorax, 
particularly as the sternum, naturally capable of making no 
great resistance, is then less so in consequence of the caries. 

The appendix xyphoides is not susceptible of derangement 
backward; for, though violently struck and driven backward 
by a blow on what is vulgarly termed « the pit of the stomach," 
yet it restores itself by its own elasticity. It may be fractured 
in aged persons, as it is then ossified; but even in that case the 
remedies are resolvents and emollients, according to the degree 
of contusion. However, as the organs contained in the epi- 
gastric region may have suffered from the same cause that pro- 
duces the fracture, it might be prudent to draw blood in pro- 
portion to the patients strength, and to confine him for a few 
days to the antiphlogistic regimen. 



CHAPTER VI. 



OF FRACTURES OF THE RIBS. 

THE ribs are placed obliquely on each side of the thorax, 
and terminate in a cartilaginous substance, by means of 
which they articulate with the sternum. This oblique direc- 
tion, and the cartilaginous termination, render them but little 
liable to fractures. Some, however, are more exposed to frac- 
tures than others: thus the first, or superior, being protected 
by the bones of the shoulder, and by the arm itself, when it 
hangs by the side, and the lower on account of their great 
flexibility, are less liable to be fractured than the middle ones. 
Fractures of the ribs differ from one another by the part of 
the bone in which the fracture takes place, by the direction of 
the fracture, and by the cause, or its way of acting. 



60 OF THE FRACTURES OF THE RIBS. 

Fractures of the ribs happen generally near the middle of 
the bone; and this is the case, whether one or more of them 
be fractured at the same time. The fracture is sometimes 
transverse, at other times oblique; in which case the fractu- 
red portions may penetrate the skin or pleura, according to the 
direction they take. 

As the cause of fractures of the ribs may act either on their 
opposite extremities, or on their middle part, a distinction of 
them has been made into fractures inwards or outwards. In 
the latter, both extremities of the rib are at the same time 
bent towards one another, so that the convexity of the rib is 
increased, and the fracture is effected when its natural extensi- 
bility is exceeded. This fracture is not without some reason 
termed outward; for it may be easily conceived that the exter- 
nal fibres are the first ruptured, and that there is a succession 
from the external to the internal side, although the fracture be 
effected almost instantaneously. This species of fracture is 
sometimes observed from the body being violently pressed be- 
tween a wall against which the back is supported, and a wheel 
of a carriage which presses on the anterior part of the breast. 

The fracture inwards is caused by a body strongly impelled 
against the middle and convex part of the rib; or when, in 
falling, that part strikes against a hard unyielding bodv; in 
which case the fracturing cause tends to straighten the rib, and 
consequently the fracture commences internally. 

In whatever manner the fracture is produced, it may be 
complicated with contusion or external wound. The sloped 
and pointed pieces of broken bone directed internally, may, 
by lacerating the pleura and substance of the lungs, give rise 
to emphysema. 

Fractures of the ribs are indicated by an acute pain felt in 
breathing. However, the part should be carefully exami- 
ned, by pressing the posterior part of the rib inward, and 
the anterior backward, and by thus ascertaining if there ex- 
ists in that part any unnatural motion, or if any crepitation 
can be produced. In fractures of the ribs the derangement 
cannot take place either in the direction of the diameter of 
the bone, nor in that of its axis or length. The ribs being 
fixed posteriorly to the spine, and anteriorly to the sternum, 
cannot shorten, as the interval between these fixed extremi- 
ties is invariable. Neither can the derangement take place by 
one of the broken pieces becoming higher or lower than the 
other, because the same muscles are attached to both frag- 



OF THE FRACTURES OF THE RIBS. 6l 

ments, and keep them at the same distance from the neigh- 
bouring ribs. The only derangement possible is the angular, 
which may be salient internally or externally, according as the 
fracture is in one or other of these directions. Experiments 
made on the dead subject, confirmed the reasoning used in 
this case. 

Having taken off the muscles which cover the thorax, I 
fractured the true ribs by placing a great weight on the ster- 
num, the body being laid on its back. This fracture was not 
attended with any derangement. If the weight on the ster- 
num was increased, or the sides of the thorax pushed forci- 
bly downward, the moveable pieces were not thereby displa- 
ced, but merely compelled to form with their contiguous ex- 
tremities a salient angle externally. This angle was salient 
internally, in a subject the ribs of which were broken by a 
violent blow of a hammer on the middle part. Whether the 
projection was internal or external, it might be effaced by 
merely distending the cavity of the thorax as hi inspiration.* 

The derangement cannot then take place, unless the mus- 
cles be torn by the violence of the blow which caused the frac- 
ture, and a portion of the rib completely detached. 

When one or more ribs are affected with simple fracture, it 
will be necessary merely to apply on the fractured part com- 
presses moistened with a resolvent fluid; which compresses 
may be kept on by means of a bandage placed round the body, 
and drawn tight enough to impede the motion of the ribs, and 
to compel the patient to perform respiration chiefly by the 
descent and elevation of the diaphragm. When the fracture 
is outward, the compresses should be pretty thick, in order to 
repress the salient angle. When it is inward, they should be 
applied on the extremities of the rib or ribs, in order to force 
outward the fractured ends which have a tendency to point in- 
wards towards the lungs. The bandage round the body is pre- 
vented from falling downwards by means of a scapulary band- 

age \ 

When the apparatus does not confine the ribs sufficiently, 

and in consequence the fractured parts move and give pain in 

the act of respiration, the quadriga ought to be applied in its 

stead. This bandage commences by a stellated cross on the 

shoulder, and it is then made to descend on the thorax in folds; 

that is, each succeeding roll covering a part of the preceding. 

* Memoirs of the Society of Medical Emulation, vol. iii. paje 159. 



6l OF FRACTURES OF THE RIBS. 

In order to render it more secure, it may be fastened with pins 
in different places. It is seldom necessary to raise the apparatus 
in order to view the state of the parts underneath, as the ec- 
chymosis disappears of itself in a very few days. 

When the violence has been considerable, and the lungs have 
been contused or lacerated by the pieces of bone, the patient 
suffers much pain, has acute fever, thirst, and difficulty of 
breathing; in short, all the symptoms of an inflammation of 
the lungs. In this case the treatment ought to be the same as 
in pneumonia; among the remedies for which, copious and re- 
peated bleedings hold the first rank. 

With respect to the emphysema, which is the name given 
to a tumour formed by the admission of air into the cellular 
texture, it may be produced by a fracture of the ribs in the 
following manner. Let us suppose that a pointed piece of bone, 
impelled into the thorax, lacerates the pleura, and vesicular 
texture of the lungs, and that the air which escapes through 
the lungs in the act 02" inspiration is received between them and 
the pleura in the cavity of the thorax. In the succeeding ex- 
piration, the cavity of the thorax becomes diminished ; the air 
contained in it being compressed, endeavours to escape by the 
part where it finds least resistance, that is, by the wound of 
the pleura; but as there may exist no external wound in the 
thorax, or even, though there did, should it be narrow and 
sinuous, the air could not escape externally; it must therefore, 
make its way into the neighbouring cellular texture, which it 
distends and tumefies. This effect of a single inspiration and 
expiration, is increased by a second, a third, &c. to the degree 
that the air may pervade the cellular texture of the w r hole body, 
except the palms of the hands and soles of the feet ; because 
in these parts certain ligamentous processes unite the integu- 
ments so closely to the subjacent aponeurosis, that the in- 
terjacent cellular texture cannot admit the air. A case of 
emphysema has been observed, in which the whole body 
had acquired a most enormous volume: the anterior side of 
the thorax was eleven inches deep. If something be not 
done to stop the progress of the emphysema, the air, after 
having filled the cellular texture under the skin, makes its 
way along the vessels into the substance of the viscera, the 
forms and functions of which it deranges, and in a short time 
destroys life. Happily this accident rarely succeeds to a frac- 
ture of the ribs. Citizen Boyer has seen only one example of 
it, which was that of a labourer, who received his death from 
the explosion of the powder-mills of Grenelle in 1793. Le- 



OF THE FRACTURES OF THE RIBS. 6$ 

dran, in his 24th Surgical Observation, makes mention of the 
case of a coachman, in whom a fracture of the fifth true rib, in 
consequence of a kick from a horse, was followed by an em- 
physema, in which the integuments were inflated to the depth 
of four inches. 

In cases of this nature, it is necessary to follow the example 
of that able practitioner ; that is, to apply pyramidal compresses 
on the part where the emphysema commences ; the compresses 
should be impregnated with some resolvent liquid, and braced 
according as the tumour collapses. 

If the emphysema, already far advanced, be still making 
progress, it will be necessary to make an incision into that side 
of the thorax where the fracture of the ribs, with lesion of 
the pleura and lungs, was suspected: the air, finding free egress 
though this wound, will no longer pass into the cellular texture. 
The validity of this precept will be rendered evident, by con- 
sidering that emphysema never follows large incised wounds of 
the thorax; and that, on the contrary, it is frequently compli- 
cated with narrow and oblique wounds made by a pointed in- 
strument, such as a small sword. 

Whatever means be adopted for arresting the progress of the 
emphysema, the air which has already passed into the cellular 
texture, loses its elasticity; its component parts combine with 
the fat and lymph contained in the cellular substance, and the 
tumefied parts return gradually to their former size. This ter- 
mination of the disease may be accelerated a little by making 
incisions in different parts of the body, and applying resolvents 
over them. 

The cartilages of the ribs cannot be broken before they are 
ossified. As long as they retain their cartilaginous structure, 
and remain supple and flexible, though they may be bent in 
towards the lungs, yet, being eminently elastic, they return 
to their natural shape as soon the external force is removed. 
Nothing, then, can be more ridiculous, nothing more dange- 
rous than the absurd practice of bone-setters for raising what 
they call " depressed ribs." Their greasy and irritating plasters 
ought also to be proscribed; for such topical applications can 
only irritate the skin, excite an erysipelatous inflammation, 
augment the pain which the contusion produces; and, by inspi- 
ring a false security, cause the consequences of the affection to 
be neglected. When the ossified cartilages are fractured in an 
old person, the treatment is the same as that for a fracture of 
any other part of the rib. 



64 



CHAPTER VII. 
OF FRACTURES OF THE BONES OF THE PELVIS. 



SECTION I. 



Of Fraclures of the Sacrum. 

THIS bone is not much exposed to be fractured: it is thick 
and of a spongy texture, deeply situated, and covered by 
a great depth of soft parts, which deaden any force that tends 
to fracture it by acting on its great diameter, or transmit that 
force to the ossa innominata, between which it is fixed as a 
wedge. Some powerful cause, such as the fall of a very heavy 
body, or the passage of a carriage-wheel on the convex side of 
that bone, can alone fracture it : it may be also fractured by a 
fall on the same part from a great height. Thus we find that 
these fractures of it, which may have different directions, and 
exist in different parts, are always produced by a force which 
has crushed the bone. No muscle tends to derange by its con- 
tractions the position of the broken portions; and the fractures 
are, therefore, dangerous only by the contusion which the 
parts contained in the pelvis may suffer; and which, by produ- 
cing effusion of blood, inflammation, and abscesses, may de- 
stroy the patient. 

The treatment of these fractures consist simply in tying a 
napkin round the pelvis, an emollient poultice being previously 
applied on the fractured part. Inflammation, and its concomi- 
tants, are prevented by bleeding, low diet, and other means, 
of which mention shall be made in treating of fractures of the 
ossa innominata. 



OF FRACTURES OF THE OS COCCYGIS. 6$ 



SECTION II. 



Of Fraftures of the Os Coccygis. 

This little bone, though much slighter than the sacrum, is, 
however, not so often fractured, because it offers no point on 
which an external force can act with advantage ; and because, 
by its mobility, it can yield to any impelled force, and return 
again to its natural position. 

When it is fractured, as by a fall on the buttocks, the pain 
which ensues, and which augments by walking, indicates the 
existence of the fracture. Some fibres of the glutsei are attach- 
ed to this bone, and by moving the fragments one on the other, 
in the act of walking, produce the painful sensation; this sen- 
sation may however, depend on the contusion, and cannot, 
therefore, be considered a proof of the existence of the fracture. 

This kind of fracture does not require any apparatus for keep- 
ing the broken pieces in a just position; although the levatores 
ani may draw the anterior fragment a little forward. Resolvents, 
or emollient poultices, as the circumstances may require, ought 
to be applied; it may be also necessary to take away some blood; 
and the most perfect repose should be enjoined, in order that 
the action of the glutsei muscles may not interrupt the conso- 
lidation. 

It is not amiss to remark here, that falls on the buttocks are 
frequently attended with bad consequences, when, from a fool- 
ish bashfulness, the patient conceals his sufferings, or refuses 
to submit to examination by a surgeon. 

Thus, the sister of a celebrated actor, who refused to submit 
to examination, although she suffered much pain in the region 
of the coccyx, allowed an abscess to form in that part, on 
opening which, the os coccygis was found fractured, and af- 
fected with caries, as Was also the inferior extremity of the 
sacrum. 



66 OF FRACTURES OF THE OSSA INNOMINATA, 



SECTION III. 



Of Fractures of the Ossa Innomitiata. 

Fractures of these bones are not frequent, but never take 
place without an attendant contusion of the external soft parts, 
and sometimes of the parts contained in the pelvis. Different 
parts of these bones may be fractured, and the fracture may run 
in different directions. The anterior and superior spinal process 
of the os ilium may be fractured, and with it the adjacent part of 
the ridge of that bone; of which we have seen an example in 
the case of a farrier, who received a kick from a horse on that 
part. The ossa pubis and ossa ischia, being protected by the 
inferior extremities, are less frequently fractured than the ilia. 
No derangement takes place in the fractured portions, whatever 
may be the direction of the fracture; not even in fractures of 
the ossa ilia, which is the more to be wondered at, as these 
bones are very thin: this immobility of the broken parts is to be 
ascribed to the thick and strong muscles which are attached in- 
ternally and externally to the broken portions. 

But these fractures are rendered very dangerous by the ex- 
travasation of blood and medullary substance into the cellular 
texture of the pelvis, and by the contusion of the parts which, 
are contained in it. "When the pelvis has been fractured by 
the passage of a wheel, by the fall of a heavy body on it r by a 
fall on the breech, the patient is entirely disabled from walking. 
If the pelvis be pressed in opposite directions, the motion of 
the broken pieces on one another will be perceived, a crepita- 
tion will be heard, and some inequalities arising from the de- 
rangement of the bones may be clearly distinguished. The 
existence of the fracture being ascertained, the surgeon's first 
care will be to obviate the consequences of inflammation by co- 
pious and repeated blood-letting. If inflammation has already 
taken place, it must be combatted by the same means; at the 
same time topical remedies are to be applied. The pelvis ought 
to be surrounded with a napkin folded in the shape of a band- 
age for the trunk; and in cases where the contusion is exces- 
sive, the bones splintered and loose, and the neighbouring 
parts disorganized, as it would be impossible for the patient to 
move or go to stool without suffering the most excruciating 



OF FRACTURES OF THE OSSA INNOMINATA. 67 

pain* it will be necessary to pass a piece of strong girth web 
under the pelvis, the corners of which, collected into one, are 
to be fastened to a pully suspended from the top of the bed: 
by means of this pully, the patient may raise himself with very 
little effort. Citizen Boyer invented this apparatus for a pa- 
tient affected in the manner we have just described: he was 
able to raise himself with the greatest ease, and to such a de- 
gree as that a flat vessel might be placed under him. It is ap- 
plicable to all cases of compound fracture of the inferior ex- 
tremities, in which it may be necessary to raise the patient fre- 
quently. 

However judicious the treatment, and well-directed the an- 
tiphlogistic remedies, the inflammatory symptoms will generally 
be so intense, that an excessive suppuration will be the conse- 
quence; and large abscesses will form, in which the pus will 
stagnate, in consequence of the great quantity of cellular tex- 
ture in that part of the body. 

Sometimes, however, the patient recovers, the effused blood 
is absorbed, and the inflammation, ends in resolution. It may 
happen too, that detached splinters shall give rise to subsequent 
abscesses, as in a case related by Maret, in the Memoirs of the 
Academy of Dijon, of a woman who had had a fracture of the 
pubis, and from whom he extracted a large portion of that 
bone through an abscess formed in the labia pudendi. 

Desault in giving an exit to a collection of urine which had 
taken place from a fracture of the pelvis, found a splinter which 
he extracted from the bottom of the wound. 

If the bladder be perforated by a splinter, this should be ex- 
tracted, and a catheter introduced into the bladder, in order to 
prevent the accumulation of urine, and its consequent effusion 
into the abdominal cavity. Chopart gives an example in Vol. II. 
of his Treatise on the Diseases of the Urinary Passages, which 
justifies this practice. 

It may be said, that artificial means are but of small effect 
in fractures of the pelvis, that the treatment must be general, 
and that even this is not always efficacious, when (as most ge- 
nerally happens) the fracture is complicated with lesion of the 
external soft parts and contents of the pelvis. 



6& 



CHAPTER VIII 



OF FRACTURES OF THE SCAPULA. 

THIS bone is seldom fractured, because, being suspended 
on the superior lateral and posterior part of the trunk, 
and moveable in that situation, it yields easily to any force im- 
pelled against it. All its parts are not, however, equally se- 
cure from fracture. The acromion, which terminates exter- 
nally its spinal process, and advances, like an arch, over the 
head of the humerus, forming thus a part of the shoulder, is 
easily fractured, because, being but thin, and lightly covered. 
with soft parts, it yields easily to a force pressing it downward, 
where it is supported only by cellular texture. The inferior 
angle of the scapula is, after the acromion, that part of it 
which is most easily fractured. The coracoid process is too 
deeply seated to be fractured, except in the case, of gun-shot 
wound: that is the only one in which J. L. Petit met an exam- 
ple of it. It has also been fractured by the fall of a heavy 
body on it; in this case, the soft parts were excessively contu- 
sed, and the patient died. 

Fractures of the scapula, whether passing from its superior 
to its inferior edge, across the spinal process, or from its ex- 
ternal to its internal edge, are always accompanied with con- 
siderable contusion, because the fracturing cause must have 
acted immediately on the part. The first mentioned, or lon- 
gitudinal fractures, are less frequent than the transverse. The 
vertical diameter being the greater, a greater force would of 
course be necessary to fracture the bone in that direction than 
in the other. Longitudinal fractures cause but very little de- 
rangement, because the muscles which are attached to the surface 
of the scapula, prevent the separation of the fractured portions. 
In transverse fractures, the derangement is not quite so trifling. 
The serratus anticus major draws forward the lower portion, 
to which it is principally attached. The rhomboides may also 
concur in producing this derangement, which is always great 
enough to be perceived by the fingers drawn along the base a 



OF FRACTURES OF THE SCAPULA. 69 

or internal side, where the inequality will be produced. In 
fractures of the acromion and inferior angle, the derange- 
ment is much more considerable. The weight of the arm, and 
the contraction of the deltoid muscle, draw downward the 
acromion, at the same time that the trapezius and levator sca- 
pulae draw the rest of the bone upward and backward. The 
serratus anticus major draws forward the lower angle, the rest of 
the scapula remaining in its natural situation ; or if the angular 
portion be considerable, the teres major and some fibres of the 
latissimus dorsi contribute to its derangement forward and up- 
ward. 

If the coracoid process is fractured, the pectoralis minor, 
the coraco-brachialis, and short portion of the biceps, concur 
in drawing it forward and downward. 

; These different fractures may be ascertained by the following 
signs: the longitudinal ones are, however, not easily distin- 
guished. If much pain be felt in consequence of a blow or 
fall on the shoulder, the part should be examined; for by feel- 
ing the scapula, and pressing it in different directions, the mo- 
tion of the broken pieces, and crepitation, may be perceived, 
particularly if the patient be not fat, and an inflammatory 
swelling has not as yet supervened. Transverse fractures are 
more easily distinguished by the inequality which they cause in 
the basis of the scapula, by the mobility of the pieces, which 
may be moved in opposite directions, by seizing in one hand 
the inferior angle, and in the other the acromion and spinal 
process. 

The derangement is so considerable in a fracture of the in- 
ferior angle, that it is impossible to be mistaken, or to overlook 
it; this part being quite detached, remains motionless, although 
the rest of the scapula should be moved. 

The pain which always attends the fracture of the acromi- 
on, and which is increased by the motions of the arm, the al- 
teration in the form of the shoulder, and the mobility of the 
acromion, which has descended, and which ascends when the 
elbow is raised close to the trunk, are the distinctive marks of 
this fracture. The small quantity of soft parts covering the 
acromion renders the discovery of it very easy. 

The contusion which constantly attends fractures of the sca- 
pula, whatever may be the part fractured, is the most dan- 
gerous symptom. Abscesses have sometimes formed in the 
fossa subscapularis in consequence of fractures of the scapula, 
and effusions have taken place in the thorax, when the frac- 



70 OF FRACTURES OF THE SCAPULA. 

turing cause has acted with such violence as to extend the con- 
tusion to the parietes of that cavity. 

When the scapula is fractured longitudinally, or transverse- 
ly, near its spinal process, it is merely necessary to fix the arm 
to the side of the trunk by means of a bandage, which in- 
cludes the arm and trunk, and which descends from the shoul- 
der to the elbow. The steadiness of this bandage is still fur- 
ther increased by applying a roller which embraces the shoul- 
der and the elbow. By binding the arm in this manner, the 
motions of the shoulder are prevented, because its motions are 
only concomitant to those of the arm. This apparatus, or 
that of Desault for the fracture of the scapula, with the omis- 
sion of the cushion for the arm-pit, is by much preferable to 
that by which the hand of the side affected is placed on the 
shoulder of the opposite side — a situation which is unnatural 
and fatiguing, and which cannot be long persevered in. 

As the inferior angle, when separated by fracture from the 
rest of the bone, is, like the condyloid process of the jaw, 
little susceptible of being acted on by any means in our power, 
it will be necessary to act on the scapula itself, to push it 
downward and forward toward the inferior fragment, which 
the serratus anticus major has drawn in that direction. 

In this case too, it is on the arm that it will be necessary to 
act, in order to move the scapula. The arm is to be pushed 
inward, downward, and forward, the fore-arm being half 
bent: it must be kept in this position by a circular bandage se- 
ven yards long. It will be proper at the same time to act on 
the angular detached portion by means of compresses, which 
may be pressed backward by some rounds of a bandage, and 
thus brought in contact with the rest of the bone. The arm 
may be supported by a sling knotted on the opposite shoulder. 

The acromion, when fractured, is drawn downward and 
outward by the action of the deltoides, at the same time that 
the rest of the bone is drawn upward and backward by the 
trapezius and levator scapulae. This fracture is set by raising 
the arm in such a manner as that the head of the humerus 
may push upward the acromion, which has descended, and 
which naturally covers it like an arched roof; at the same time 
an assistant pushes the scapula forward and downward in a di- 
rection opposed to that which is given the arm. In order that 
the parts may remain in this situation, it will be necessary that 
the action by which they have been placed in it be perpetuated 
by bandages; that is, that the arm be supported parallel to the 



OF FRACTURES OF THE SCAPULA. *J I 

trunk, and that the shoulder be pressed downward at the same 
time. 

To effect this, a circular bandage is applied round the trunk 
and arm, and afterwards made to ascend from the elbow 
to the shoulder, and vice versa. In this last direction, the 
bandage has the advantage of securing on the shoulder the 
compresses, moistened with a repellent liquid, of raising the 
humerus against the acromion, of which it ought to be the 
support while nature effects the consolidation, and pressing 
down the scapula to the level of the acromion. This bandage, 
like all those of the thorax, is very liable to be displaced, on 
account of the motion of the thorax; it ought, therefore, to 
be frequently reapplied, never forgetting on these occasions to 
have the elbow raised, and the shoulder pressed down. 

Although fractures of the scapula consolidate in the ordinary 
time of from thirty-five to forty days, yet in those of the acro- 
mion it will be necessary to continue the bandage a little longer: 
not that the generation of callus is slower in that part of the 
bone than in any other, but because that process is acted on by 
two strong muscles, which might rupture the callus, if expo- 
sed to their action before it had acquired a great degree of so- 
lidity. 

To these mechanical means general remedies may be ad- 
ded, such as blood-letting, &c. The consequence of these frac- 
tures are seldom dangerous. A case has been given, however, 
in which the cellular texture which unites the subscapulars 
muscle to the depression of that name, became inflamed, sup- 
purated, and a deep-seated abscess was formed, for which it 
was found necessary to trepan the scapula. A person received 
a thrust of a sword in the shoulder; the weapon, after having 
penetrated the integuments and infraspinatus muscle, pierced 
also the scapula, and wounded the subscapulars muscle. The 
inflammatory symptoms were intense, and an abundant sup- 
puration took place. In order to stop the suppuration, Mare- 
chal enlarged the fistulous orifice by trepanning the scapula. 
The operation was attended with success, as we learn from the 
author of its eulogium, which is found at the commencement 
of the second volume of the Memoirs of the Academy of Sr.r*> 
gery. 



n 



CHAPTER IX, 



OF FRACTURES OF THE CLAVICLE. 

MANY causes conspire to render the clavicle liable to 
fracture: it is long and slender, supported in its mid- 
dle part only by cellular texture -, and protected externally but 
by a very thin covering of soft parts. But its functions con- 
tribute much more than these circumstances to render the frac- 
ture of it frequent. It serves to keep the scapula at a proper 
distance from the sternum, and acts as a point d'appui to the 
humerus, every impulse of which it receives and transmits to 
the sternum. 

A fracture of this bone may take place in any part of its 
length, but it most frequently happens near its middle, because 
its curvature is greatest at that part. Sometimes, but rarely, it 
takes place near the extremity, articulated with the scapula. — - 
Fractures of it may be transverse or oblique -, simple, or com- 
plicated with contusion, wound, or detached splinters — differ- 
ences which depend on the action of the fracturing cause. A 
blow on the shoulder, and of sufficient momentum^ will, as it 
acts directly, fracture the bone in that part on which it is in- 
flicted, and will at the same time lacerate or contund the soft 
parts. A comminutive fracture may be produced by this 
means j and if the violence be sufficiently great-, the subclavian 
vessels, and nerves which lie between the clavicle and first rib 
may be torn; and a paralysis of the arm produced: this affec- 
tion frequently follows the fall of a heavy body on the shoul- 
der. 

If the fracture be caused by contre-coup, in which case the 
fracturing force is immediately applied to the ends of the bone, 
it is not necessarily complicated with contusion. A fracture 
may be occasioned in this way by a fall on the point of the 
shoulder, or on the hands, the arms being extended. It may 
happen, however, in this case, that the clavicle, pressed very 
forcibly against the sternum, may be bent much beyond its 
natural curve, and fractured so obliquely, that the broken por- 
tions shall pierce through the integuments. 



OF FRACTURES OF THE CLAVICLE. 7J 

Fractures of the clavicle are generally attended with de- 
rangement of the broken portions, those, however, excepted, 
which take place near the extremity articulated with the sca- 
pula, and within the coraco-clavicular ligaments. Although 
the bone be very slender in this part, yet it is so strongly at- 
tached to the scapula by these fibrous productions, that the 
derangement is scarcely sufficient to indicate the existence of 
the fracture. 

The mechanism of the derangement of the pieces is easily 
understood: the external portion is that which is always de- 
ranged, because the internal, retained in its articulation by the 
costoclavicular ligaments, and drawn in opposite directions by 
the sterno-cleido-mastoideus, and pectoralis major, is immova- 
bly fixed. The external fragment, on the contrary, being 
weighed down by the arm, and drawn in the same direction 
by the action of the deltoides, and being at the same time 
drawn forward and inward by the pectoralis major, is carried 
under the internal portion, which forms an eminence over 
it. 

From the moment that the fracture of the clavicle allows the 
shoulder to approach the sternum, the arm falls on the fore 
part of the breast; and the patient resembles in that particular, 
an animal without a clavicle. 

One of the principal signs of fracture of the clavicle, is the 
impossibility which the patient finds of applying the hand of 
the side affected to his forehead, because that act requires a 
semicircular motion of the humerus, which cannot be perform- 
ed if that bone has not a firm point d'appui. If the patient 
attempts this motion of the arm, it may be remarked that he 
merely bends the fore-arm and inclines his head, in order to 
bring the hand and forehead into contact. In addition to this 
sign, it will be observed, that the shoulder and superior extre- 
mity are placed more anteriorly on the breast and nearer the 
sternum, than in their natural state, or than those of the op- 
posite side. The patient leans to the fractured side; and if 
the part be examined before a swelling and inflammation has 
come on, the motion of the pieces on one another may be 
perceived, and the projection formed by the end, generally of 
the internal portion, will be evident. A crepitation may be 
produced by the motion of the shoulder, but not without 
causing great pain. These signs, independently of preceding 
circumstances, establish clearly the diagnosis of fractures of 
the clavicle, 

10 



74 OF FRACTURES OT THE CLAVICLE. 

If the soft parts have suffered no extraordinary contusion, a 
fracture of the clavicle is not dangerous; but if the fracture be 
comminutive, the soft parts lacerated, and the nerves of the 
brachial plexus injured, much danger may result from it. 

For no fracture have so many bandages and so much appa- 
ratus been invented, as for that of the clavicle. We shall ex- 
amine them successively, and point out their defects and per- 
fections. The ancients and many of the moderns have ima- 
gined, that in order to set a fracture of this bone, it was ne- 
cessary to have the shoulder drawn back, and fixed in that 
position: to effect this, it was ordered that the patient should 
be placed on a low stool, so that an assistant might place his 
knee between his shoulders, which he drew back at the same 
time with both his hands, whilst the surgeon applied the band- 
age, which was to keep the parts in this position. It is easy to 
perceive that in thus drawing the shoulders toward one ano- 
ther, the scapula is pushed toward the sternum, and with it 
the external portion of the clavicle, which passes under the in- 
ternal. If this portion be sharp pointed, and the shoulders 
drawn back with great force, it may lacerate and pierce the 
integuments. The bandage in form of the figure 8, with 
which it is attempted to keep the parts in this position, does 
not correct the defect in any degree. The manner of its ap- 
plication is as follows: While the assistant acts as above men- 
tioned, the operator applies one end of a seven yard bandage, 
rolled up in one, to the arm-pit of the side affected, and 
draws it obliquely to the opposite shoulder, round which it is 
made to pass, and from this to the other shoulder, about 
which it is to be rolled in the same manner, and crossed after- 
wards repeatedly before and behind. As this bandage acts ob- 
liquely, its force is decomposed; it is therefore necessary to 
draw it very tight, in order to keep the shoulders back. But 
this extreme constriction of the bandage excoriates the parts 
about the arm-pits, particularly in cases of women, and causes 
much distress, without producing any good; besides, the 
drawing back of the scapulae forces the fractured portions to 
overlap, which is the very reverse of the desired effect; but 
luckily the obliquity of its action prevents it from acting so 
forcibly as to confine the shoulders.; even though, as prescri- 
bed by J. L. Petit, they should be braced behind by a com- 
press. The iron cross proposed by Heister, the corselet de- 
scribed by Brasdor in the Memoirs of the Academy, and the 
leather strap proposed by Brunninghaussen, are only modifica- 



OF FRACTURES OF THE CLAVICLE. 75 

tions of the figure of S bandage, and have no advantage over 
it. All aft obliquely on the shoulders, tend to effect a de- 
rangement of the fractured portions, by drawing the scapulae 
toward one another, excoriate the parts about the arm-pits, 
and do not prevent the descent of the arm. 

The general rules which we have given for setting fractures, 
are to be attended to in those of the clavicle. Extension is to 
he performed by means of the limb, which articulates with the 
fractured bone, and in the direction of this latter. This dou- 
ble purpose is answered by using the humerus as a lever of the 
first species, that is, by bringing its inferior extremity forward, 
inward, and upward, and pushing the shoulder backward, up- 
ward, and outward: the humerus may be converted into a le- 
ver of the first species, by placing a cushion in the arm-pit, 
which cushion will act as a fulcrum to the lever. 

The Arabians, and Ambrose Pare, saw, though indistinctly, 
the necessity of this practice, and now and then had recourse 
to it; but it remained for Desault fully to develope it, and in- 
vent an, appropriate apparatus. 

The practice of this celebrated surgeon consisted in applying 
in the arm-pit a cushion, made of hair or flocks, five or six inches 
long, and three inches and a quarter thick at its base. To the 
corners of its base, placed upward, are fastened two strings, 
which being passed across the back and breast, are to be tied 
on the opposite shoulder. The cushion being thus placed, the 
surgeon seizes the patient's, elbow, the. fore-arm being bent, 
and brings it forward, upward, and inward, pressing it with 
force against the breast. By this manoeuvre the humerus car- 
ries the shoulder outward; the ends of the fractured portions 
are placed opposite one another, and the deformity disappears. 
All that is then necessary, is to fix the arm in, that situation, 
and prevent it from moving all the time that nature requires 
for the consolidation of the fracture. For this purpose an as-? 
sistant supports the arm in the position given to it by the sur- 
geon; while he takes a bandage nine yards long, rolled up in 
one, and places one end of it in the arm-pit of the opposite 
side, and draws it from thence over the superior part of the 
arm, and across the back to the same part. This first cast of 
the bandage is exactly covered by another, which secures it, 
and, the succeeding casts are made to overlap one another one 
third, until the arm is covered down to the elbow; taking care 
at the same time to draw the bandage tighter in proportion as 
it descends; because the bandage must be considered as the. 



y6 OF FRACTURES OF THE CLAVICLE. 

force which acts on the lever; for which reason it should ope- 
rate particularly on its extremity. 

This first bandage being applied, compresses impregnated 
with camphorated spirit, or any other resolvent fluid, are pla- 
ced along the fractured bone. Then, another bandage as long 
as the former, is taken by the operator, and one end of it 
placed under the arm -pit of the opposite side, from whence it 
is drawn across the breast over the compresses and the fractur- 
ed part, down behind the shoulder and arm, and upward on 
the breast, after having passed under the elbow; it is then 
brought across to the sound shoulder, under and round which 
it is passed, in order to secure the first cast; it is then drawn 
across the back, brought over the compresses, carried down 
before the shoulder and arm, under the elbow, and obliquely 
behind the back to the arm-pit, where the application com- 
menced. The same process is repeated until the bandage is 
entirely applied. The principal use of this bandage is to sup- 
port the arm; it admits therefore of some variety in its appli- 
cation. By means of these two bandages, the external broken 
portion is raised upward, and pushed outward, and therefore 
the two principal objects are attained. The whole apparatus 
may be still further fixed and secured, by pinning the bandage 
where it appears to have any effect. Finally, the hand is to 
be supported by means of a sling. 

It has been recommended to make the cushion for the arm- 
pit of old linen, but hair or flocks are preferable for that pur- 
pose. A cushion made of them is soft, and will not benumb 
the arm by compressing the brachial plexus, or occasion an in- 
flammation or gangrene of the parts. 

It must be allowed that this bandage of Desault fulfils every 
indication of cure; but it has a disadvantage necessarily attend- 
ant on every such bandage, passed by a great number of casts 
round a part so bulky as the trunk, it is easily deranged. The 
dilatation of the thorax contributes much to this effect, parti- 
cularly in women. It has a further disadvantage with respect 
to females, namely, its pressure on the mamma?, which must 
make it at least very troublesome. In both man and woman it 
renders respiration difficult. To these disadvantages may be 
added that arising from the difficulty of applying it, on ac- 
count of the number of pieces of which it consists, and the 
length of time required for its application. Every time that it 
becomes deranged, it will be necessary, in order to re- apply it. 



OF FRACTURES OF THE CLAVICLE. 77 

to raise the arm and move the shoulder more or less, which 
motion counteracts the consolidation of the fracture. 

Convinced by his own experience, of these disadvantages of 
Desault's apparatus, Citizen Boyer has invented the following 
one, more simple and less troublesome; by means of which he 
has effected a complete cure of a fracture of the clavicle, 
without deformity. 

It consists of a girdle of linen cloth, quilted, and six inches 
broad, which passes round the trunk on a level with the elbow: 
it is fixed on by means of three straps, and as many buckles 
fastened to its extremities. At an equal distance from its ex- 
tremities are placed externally on each side two buckles: that is, 
two anterior and two posterior to the arm. A bracelet of 
quilted linen cloth, five or six fingers broad, is placed on the 
lower part of the arm of the side affected, and laced on the 
outside of the arm; four straps fixed to this bracelet, that is, 
two before and two behind, correspond to the buckles on the 
outside of the girdle, already described, and answer the pur- 
pose of drawing the lower part of the arm close to the trunk; 
the more so as the straps, by being two before and two behind, 
prevent the arm from moving either backward or forward. 
With this apparatus, as well as with the preceding, the cushion 
must be applied under the arm. 

Nothing can be easier than the treatment of a simple frac- 
ture by means of this apparatus, the use and application of 
which may be more easily conceived by the assistance of the 
engraving at the end of this volume. The patient himself may 
tighten the straps and press the elbow to the trunk, whenever 
it is found necessary. He may quit his bed in a few days and 
walk about, having the hand and fore-arm supported in a sling. 
A fracture of the clavicle is frequently consolidated in thirty 
days, during which time the patient need not be confined to 
any very strict regimen. 

These fractures, when compound, are treated as directed 
in Chapter I. In some cases it may be necessary to rub an irri- 
tating substance on the arm, when a paralytic affection of it re- 
mains. If the fracture be double or comminutive, it will be 
well to apply a flexible splint over the compresses moistened 
with a resolvent liquid, as already directed. 

If Desault's bandage be employed, it will be necessary to re- 
new it as often as it becomes slack; and we believe that its ha- 
ving been found unsuccessful by several practitioners, is to be 
ascribed to the neglect of this particular circumstance. 



7 8 



CHAPTER X. 



OF FRACTURES OF THE HUMERUS. 

THIS bone may be fractured in any point of its length : in 
the middle, at either extremity, or above the insertion of 
the pectoralis major, latissimus dorsi, and teres major. The af- 
fection in this last-mentioned case is termed fracture of the neck 
of the humerus; but that denomination has not the merit of 
being strictly anatomical. It is possible, however, that what 
is strictly called the neck of the humerus may be fractured, par- 
ticularly by a gun-shot wound. By neck of the humerus, we 
understand that circular narrowing which separates the tube- 
rosities from the head. 

The fractures of this bone may be transverse or oblique, sim- 
ple or compound. In short, whatever has been said of the 
differences of fractures in general, is applicable to those in par- 
ticular. The same may be said of the causes, whether acting 
on the extremities of the bone, or immediately on the part 
fractured. 

The transverse fractures of the middle part under the inser- 
tion of th.e deltoid muscle, are attended with but a trifling de- 
rangement. The anterior brachialis and triceps brachialis, at- 
tached posteriorly and anteriorly to both fractured portions, 
counteract one another, and admit only a slight angular de- 
rangement. When the fracture takes place above the insertion 
of the deltoid muscle, the inferior portion is first drawn out- 
ward, and then upward on the external side of the superior. 
Fractures of the humerus, near its lower end, such particularly 
as are transverse, are not subject to much derangement: an ef- 
fect which is to be attributed to the breadth of the fractured sur- 
faces; to their being covered posteriorly by the triceps brachi- 
alis, and anteriorly by the brachialis anterior, which admit only 
a slight angular derangement by the inferior portion being 
drawn a little forward. 

The oblique fractures are always attended with derangement, 
whatever be the part fractured. The inferior portion being 



OF FRACTURES OF THE HUMERUS. 7J 

drawn upward by the action of the deltoides, biceps, coraco- 
brachial, and long portion of the triceps, glides easily on the 
superior, and passes above its lower extremity. Finally, frac- 
tures of the neck of the humerus are always attended with de- 
rangement, which is produced by the action of the pectoralis 
major, latissimus dorsi, and teres major, which being attached 
to the lower portion near its superior extremity, draw it first 
inward and then upward, in which last direction it is powerful- 
ly aided by the biceps, coraco-bracbialis, and long portion of 
the triceps. The superior portion itself is, in this case directed 
a little outward by the action of the infraspinatus, supraspinatus, 
and teres minor, which make the head of the humerus perform 
a rotatory motion in the glenoidal cavity. 

We proceed to examine the different marks by which these 
fractures may be ascertained. 

The shortening and change in the direction of the limb, the 
crepitation, which may be very distinctly perceived by moving 
the broken pieces in opposite directions, the pain, and impos- 
sibility of moving the arm, &c. joined to the history of the 
preceding circumstances, render it easy to establish a diagnosis. 
It may happen however, from ignorance or inattention, that a 
luxation of the cubitus may be mistaken for a fracture of the 
lower extremity of the humerus. In treating of luxation, we 
shall state how this mistake, which might be of the most dan- 
gerous consequence, may be avoided. 

Fractures of the neck of the humerus are not so easily ascer- 
tained, and have been frequently, for want of attention, con- 
founded with luxations of that bone. The diagnostic symp- 
toms of these two affections are however very different. 

When the neck of the humerus is fractured, a depression is 
observed at the superior extremity and external side of the arm, 
which is very different from that accompanying the luxation 
downward and inward of that bone. In the latter case, under 
the projection of the acromion, a deep depression is found in 
the part which the head of the humerus naturally occupies j 
whereas, in the fracture of the neck of that bone, the shoulder 
retains its natural form, the acromion does not project, and 
the depression is found below the point of the shoulder. Be- 
sides, in examining the arm-pit, instead of finding there a round 
tumour formed by the head of the humerus, the fractured and 
unequal extremity of that bone will be easily distinguished, 
The motion of the broken portions, and the crepitation which 



80 OF FRACTURES OF THE HUMERUS* 

may be produced by moving them, serve still further to esta-* 
blish the diagnosis. 

A simple fracture of the body of the humerus is not a very 
dangerous affection: in that near the extremities, the danger 
is greater, because, as has already been mentioned, inflamma- 
tion and false anchylosis are more to be apprehended, and the 
management of the fracture is more difficult. 

Transverse or oblique fractures of the humerus are easily 
set. An assistant placed on the side not affected, and having 
his hands passed before and behind the thorax, fixes the shoul- 
der, while another draws down the humerus, by seizing the 
fore-arm, or even the condyloid processes of the humerus: the 
operator then places the fractured surfaces in proper contact. 
The criterion of the fracture being well set, is the arm having 
its proper length, form and direction, so that the external con- 
dyloid process or tuberosity of the humerus may correspond 
with the most salient part of the shoulder. When the frac- 
ture is thus set, the surgeon takes a bandage eight yards long- 
rolled up in one, and having placed some lint in the palm of 
the hand, commences the application of the bandage on that 
part, drawing by its means the fingers close together, after 
which it is rolled upward on the rest of the arm, each cast 
covering a part of the preceding. When it is brought as far 
as the elbow, the fore-arm is to be bent; and when carried 
as high as the depression under the insertion of the deltoides, 
some lint is to be placed under it, in order that the com- 
pression may be as equal as possible; the whole arm is to be 
covered alike; but three folds one over the other, are to be 
made on the situation of the fracture. When the bandage has 
reached the shoulder, four thin splints of wood, or, still 
better, of tin, slightly convex, are to be applied one oppo- 
site the other on the arm; or, if the arm be very slender, 
three splints may suffice. While an assistant holds these splints, 
they are fixed by turns of the bandage carried downwards, 
which cover one another partially as before. The bandage is 
brought up again in the same manner; and, if long enough, 
down again on the arm and fore-arm. The turns of the band- 
age which serve to fix the splints, ought not to be drawn so 
tight as to cause pain. 

It is indispensably necessary to apply the bandage on the 
hand and fore-arm, as otherwise these parts would tumefy, on 
account of the circulation in the veins and lymphatics being 
obstructed. This obstruction, though not very painful, is at 



OF FRACTURES OF THE HUMERUS. 81 

least troublesome. Besides, the articulation is rendered stiff 
by the swelling, and the stagnant fluid becoming thick, con- 
duces very much to produce a false anchylosis. Should this 
precaution have been omitted at first, the bandage should be 
applied even after the swelling has taken place. It is scarcely 
necessary to say, that every part of the bandage ought to be 
impregnated with some resolvent liquid: independently of the 
repellent effects of the liquid, the bandage can be better appli- 
ed when wet than when dry. 

If the patient keep his bed, a pillow should be placed un- 
der the arm; on the contrary, if he remain up, it will suffice 
to support the hand half prone in a sling. If the patient be 
very vigorous, it will be prudent to draw some blood, and to 
put him on a very low diet for some time. If no bad symp- 
tom come on after the application of the apparatus, it need 
not be taken off before the fifth day, and afterwards every 
eighth or tenth day, so that the consolidation will be found 
perfect at the fourth or fifth removal. It should be more fre- 
quently re-applied for a fracture of the lower extremity of 
the humerus. The articulations of the elbow and shoulder 
should be frequently moved, in order to prevent a false anchy- 
losis ; but the motion should not be attempted before the callus 
has acquired a certain degree of solidity. 

If the fracture be complicated with violent contusion, and 
great inflammation be inevitable, or already established, the 
limb should be placed on a pillow, the fore-arm half bent, the 
hand prone, and a little raised, in order to facilitate the circu- 
lation in the veins and lymphatics. Scultet's bandage is first 
applied, its separate pieces being previously extended on a 
linen cloth as long as the humerus; the splints are rolled in 
this cloth, and applied over the bandage, care being taken to 
place little chaff bags where they may be necessary, as, before 
directed. The strings or tapes with which the whole is to be 
bound externally, should not be drawn too tight. It will be 
necessary to apply emollient poultices on the arm, when the 
resolvent applications do not discuss the swelling. By accom- 
panying these means with the general treatment in similar ca- 
ses, such as bleedings, rigorous abstinence, diluent and cool- 
ing drinks, the inflammatory symptoms disappear in seven or 
eight days, and the rolled bandage, as last described, may be 
substituted for that of Scultet. If the fracture be comminu- 
tive, or complicated with wound, the treatment will vary as 
directed in Chapter I. on the General Treatment of Fractures. 
11 



$2 OF FRACTURE5 OF THE HUMERUS. 

It has been advised in fractures of the lower extremity of 
the humerus, to place the four splints in such a manner as that 
they should extend equally on the arm and fore-arm, care be- 
ing taken to equallize the anterior and posterior sides, particu- 
larly the bend of the arm and olecranon, with the rest of the 
limb, by means of graduated compresses properly disposed. — 
But this extension of the whole member would be painful, and 
might produce a false anchylosis of the elbow. 

If the case require it, four splints may be so hinged in their 
middle part, as that the anterior and posterior ones should 
open or close up on their breadth, and the two lateral ones on 
their edges. Instead of these hinged splints, Citizen Boyer 
has successfully employed four simple splints for the humerus, 
and four more for the fore-arm. 

The fracture of the neck of the humerus requires a mode of 
treatment which it is necessary to particularize. It has been 
proposed in this case to apply the spica, or the eighteen tailed 
bandage, and other means ecpally insufficient. Moscati, a 
surgeon of Milan,, sensible of the difficulty of acting in these 
cases, on the superior portion, invented a means by which this 
inconvenience was overcome. This consisted in filling the 
arm-pit, previously covered with a cloth fastened on the out- 
side of the shoulder with tow soaked in a mixture of alum and 
the white of an &gg beat up together. He covered the shoul- 
der with a similar preparation, and over that applied the spica 
bandage. This mixture dried up rapidly, and formed- a hard 
crust round the part. This mode of treatment (described by 
the author in the Memoirs of the Academy of Surgery) has a 
great disadvantage; it forces the patient to keep his arm at a 
distance from the trunk; and this strained and unnatural po- 
sition is incompatible with the exact juxta-position of the bro- 
ken portions, the situation of which cannot be known while 
covered bv this substance. 

Ledran thought of combining this invention of Moscati's 
with the means used by the ancients, which consisted in ma- 
king the trunk serve as an internal splint, and binding the aj^n 
to the trunk by a circular bandage. This correction by Le- 
dran led to the invention of the bandage for the clavicle, the 
application of which Desault extended to fractures of the neck 
of the humerus. According to this method, the arm is en- 
veloped by a bandage, and the elbow pressed toward the 
breast, a cushion being first placed in the arm-pit: another 
circular bandage is then passed round the arm and trunk. 



OF FRACTURES OF THE FORE-ARM. 8 J 

splints are applied to the anterior, posterior, and lateral parts 
of the arm, and some compresses wet with a resolvent liquid 
are applied on the shoulder. 

By means of this apparatus, fractures of the neck of the 
humerus consolidate as easily, and sometimes in less time than 
those of its middle part. 

It sometimes happens, that in young subjects the head of 
the humerus, being yet but an epiphysis, separates from the 
rest of the bone in consequence of a blow or fall; which af- 
fection, both as to the diagnostic symptoms and treatment, is 
analogous to a fracture of the same part in a more advanced 
age. It is, however, particularly necessary in this case, to fill 
the arm-pit so as to throw outward the lower portion of bone ; 
because, if the parts be not exactly and fairly united, the mo- 
tions of the arm will be impeded to a certain degree for ever 
after. 

In compound fractures of the neck of the humerus, as well 
as in those of the body of that bone, no attempt is to be made 
to set the fracture till the inflammatory symptoms have subsi- 
ded/ 



CHAPTER XI. 



OF FRACTURES OF THE FORE.ARM. 

SOME authors have denominated complete, those fractures 
of the fore-arm in which both bones are fractured: and 
incomplete, those in which one only is fractured. We have 
already given it as our opinion that these denominations are 
fallacious, and we will substitute for them that of fracture of 
the fore-arm, when both the bones of which it is composed 
are fractured; and that of the radius or cubitus, where only 
one of these bones is fractured. 



84 OF FRACTURES OF THE FORE-ARM, 



SECTION I. 



Of Fra&ures cf the Fore-arm. 

They are almost always the consequence of a fall, or blow 
on the fore-arm, and take place in the part on which the cause 
has immediately acted. It is difficult to imagine, that, by a 
fall on the palm of the hand, both bones could be fractured at 
once, because the radius alone receives the impulse communi- 
cated by the hand: the cubitus having no immediate connexi- 
on with the hand, cannot be often fractured by this cause. 

These bones may be fractured on the same level, as most 
frequently happens, or the fracture of one may be higher than 
that of the other. Fractures of these bones, whether trans- 
verse or oblique, are generally complicated with greater or less 
contusion, wound., detached splinters, and other concomitants 
of affections of this kind. 

The connexion of the two bones of the fore-arm, by the in- 
terosseous ligament which occupies the interval by which they 
are separated, and the manner in which the muscles which are 
attached to both, are inserted into them, render the derange- 
ment of the broken pieces in the longitudinal direction very 
difficult; and, in reality, a derangement in this direction has 
been seldom observed, and never to any considerable degree: 
when it does take place, it is to be ascribed to the cause of the 
fracture rather than to muscular contraction. The derange- 
ment in the direction of the diameter, on 1 the contrary, always 
takes place in such a manner as that the four pieces approach 
one another, and the interosseous interval diminishes, or is en- 
tirely obliterated at that part near the seat of the fracture^ 
which approximation of the ends of the bones causes an evi- 
dent deformity of the part. 

To this derangement must be added the angular, which the 
fracturing cause always produces, either forward or backward, 
according to its direction. 

The existence of these fractures is easily ascertained from 
the history of the circumstance, from the pain, which is ren- 
dered more acute by moving the hand, from the impossibility 
of performing pronation or supination of the hand, and from- 
the noise produced by the friction of the fractured surfaces 



OF FRACTURES OF THE FORE-ARM. 85 

whenever these motions are attempted; finally, from the 
change in the form of the arm, the anterior and posterior sides 
of which appear tumefied by the protusion of the muscles 
which the broken bones have displaced from the interosseous 
interval^ the other sides being depressed, and from the mobi- 
lity of the broken portions, and change in the direction of the 
arm. 

When these bones are fractured near their inferior extremi- 
ties, the inflammatory swelling might render a diagnosis less 
clear, and cause the fracture to be mistaken for a luxation of 
the hand. But the two cases may be distinguished by simply 
moving the hand ; by which motion, if there be luxation with- 
out fracture, the styloid processes of the radius and cubitus 
will not change their situation; but if a fracture do exist, 
these processes will follow the motion of the hand. 

In order to adjust a fracture of these bones, the fore-arm is 
bent to a right angle with the arm, and the hand placed in a po- 
sition between pronation and supination. The fore-arm and 
hand being thus placed, an assistant seizes the four fingers of 
the patient, and, by pulling, extends the fractured parts, while 
another assistant makes counter extension by fixing the hume- 
rus with both his hands. By these means the operator is ena- 
bled to restore the bones to their natural situation, and to push 
the soft parts into the interosseous space, by a gentle and gra- 
duated pressure on the anterior and posterior sides of the arm. 
Coaptation is very easy in fractures of these bones, as are in- 
deed all the other parts of the operation, in which effort and 
violence are not at all required. 

The fracture being thus set, the bones are kept in their 
place by applying first on the anterior and posterior sides of 
the fore-arm two longitudinal and graduated compresses, the 
base of which is to be in contact with the arm. The depth 
of these compresses should be proportioned to the thickness 
of the arm, increasing as the diameter of the arm diminishes. 
In the next place, the surgeon takes a bandage about six yards 
long, rolled up in one, and makes three turns of it on the 
fractured part, descends then to the hand by casts partially su- 
perposed on one another, and envelopes the hand in passing 
the bandage between the thumb and index: the bandage is 
then carried upward in the same manner, and reverted where- 
ver the inequality of the arm may render it necessary. The 
Compresses and bandage being thus far applied, the surgeon 
Jays on two splints, one anteriorly, the other posteriorlv, and 



86 OF FRACTURES OF THE FORE-ARM. 

passes the part of the bandage that yet remains over them, in 
such a manner as entirely to cover them. It may not be unne- 
cessary to remark, that the compresses and splints should be 
of the same length as the arm. It would be useless to employ 
lateral splints in this case, unless (what is scarcely ever to be 
expected or met with) a derangement should have taken place 
in that direction. It is evident, that lateral splints would coun- 
teract the compresses and two other splints, by increasing the 
radio-cubital diameter of the arm, and by concurring with the 
action of the pronatores to move the pieces into the interosse- 
ous space. The surgeon's attention should be most particular- 
ly directed to preserve the interosseous space; for, if this be 
obliterated,, the radius cannot rotate on the cubitus, nor the 
motion of pronation or supination be executed; and this ob- 
ject may be obtained with certainty by applying the compresses 
and splints in such a manner as that the fleshy parts may be 
forced into, and confined in, the interosseous space, and by 
renewing the bandage every seven or eight days. 

Such is the treatment of a simple fracture of the fore -arm: 
If the contusion be excessive, with wound or comminutive 
fracture, the splinters should be extracted, the arm placed on 
a pillow, and dressed with the usual topical applications adapt- 
ed to the degree of inflammation, the patient bled, and Scul- 
tet's bandage applied. If the inflammatory symptoms continue 
a certain length of time, the bones consolidate in a manner 
that deforms the arm, and renders it impossible to perform the 
movements of pronation and supination: this may be prevent- 
ed, if the inflammatory symptoms disappear so much on the 
fifteenth or twentieth day as to admit the application of the 
apparatus for simple fractures. 

If the fracture be simple, and the contusion inconsiderable, 
it will not be necessary to confine the patient to bed: he may 
be allowed to walk about and attend to his business, having 
the arm supported in a sling. The consolidation is generally 
perfect in thirty or forty days, no difference being perceivable 
in the time necessary for the generation of the callus in the 
case in which the two bones are fractured, and that in which 
only one is broken. 



OF FRACTURES OF THE RADIUS. 87 



SECTION II. 



Of FraBures of the Radius. 

Of all fractures of the fore-arm, this is the most frequent; 
the radius being almost the sole support of the hand, of which 
it has been called the manubrium) and being in the same line 
with the humerus, is for both these reasons more exposed to 
fracture than the cubitus, which corresponds with the hand 
only by a very small surface, and which does not form a 
strait line with the humerus. 

Fractures of this bone, whether transverse or oblique, near 
its middle part or extremities, may be caused by a fall or blow 
on the fore-arm, or, as happens in most cases, by a fall on the 
palm of the hand. When the body is thrown off its centre of 
gravity, and falling appears inevitable, we are apt from habit to 
extend our arms, and let the hands come first to the ground; 
in which case the radius, pressed between the hand which is 
supported on the ground, and the humerus, from which it re- 
ceives the whole momentum of the body, is bent, and if the 
fall be sufficiently violent, broken more or less near its middle 
part. When after an accident of this kind, pain and a diffi- 
culty of performing the motions of pronation and supination 
supervene, the probability of a fracture of the radius is very 
strong. The truth is fully ascertained by drawing the hand 
along that bone on the external side of the fore-arm, with as 
great a degree of pressure as the pain excited will admit : be- 
sides, in endeavouring to perform supination or pronation of 
the hand, a crepitation will be heard, and the moving of the 
broken portions perceived, if the bone be in reality fractured ; 
but it is not amiss to warn against mistaking the noise made by 
the tendons of the muscles of the thumb which wind on the 
inferior and exterior part of the radius, for a crepitation pro- 
duced by the rubbing of the fractured surfaces. These tendons 
are thick and dry in labouring people, and cause a certain noise 
on being moved in their sheaths, in which there is a scarcity 
of synovia. This noise is easily distinguished from crepitation 
by an experienced ear. When the fracture takes place near 
the head of the radius, the diagnosis is more difficult on ac- 
count of the. depth of soft parts over the bone in that part. In 



83 OF FRACTURES OF THE RADIUS. 

this case the thumb is to be placed under the external condyle 
of the os humeri, and on the superior extremity of the radius, 
and at the same time the hand is to be brought to the prone 
and supine positions. If in these trials, always painful, the 
head of the bone rests motionless, there can be no doubt of its 
being fractured. The causes of derangement are here the same 
as in fractures of the fore-arm, and it can never take place but 
in the direction of the diameter of the bone, and is effected 
principally by the action of the pronating muscles. The cubi- 
tus serves as a splint in fractures of the radius; and the more 
effectually so, as these two bones are connected with one ano- 
ther in their whole length. Notwithstanding the evidence of 
the mechanism which prevents the longitudinal derangement, 
J. L. Petit has thought that derangement possible. 

Extension and counter-extension are made in the same way 
as in fractures of both bones of the fore arm, with this slight 
difference, that the assistant who makes the extension should 
incline the hand to the cubital side of the fore-arm. Great 
care is to be taken, that, by means of graduated compresses 
placed on the anterior and posterior sides of the fore-arm, the 
natural shape be restored, the convexity produced by the frac- 
ture removed, and that the bandage may act principally on the 
extremities of the dorso palmaris diameters, by which action 
the fleshy parts will be pressed in between the two bones, and 
therefore these bones kept separate, and the interosseous space 
preserved to the extent which is natural, and which is necessa- 
ry for the pronation and supination of the hand. 

It would be superfluous to repeat here what has been said in 
the preceding section on the mode of perfecting the cure, and 
combatting the symptoms which might complicate the fracture: 
the treatment in this respect being absolutely the same in both 
cases. 



SECTION III. 



Of Fraffures of the Cubitus. 

Fractures of this bone, less frequent than those of the radius 
for the reasons already mentioned, take place generally at its. 
lower extremity, because it is smaller and less covered at that part 



OF FRACTURES OF THE CUBITUS. 89 

than at any other; consequently we find, that a fracture of 
this bone is almost always the result of a force acting immedi- 
ately on the part fractured; as, for instance, when one falls 
and strikes the internal side of the fore-arm against a hard re- 
sisting body. On applying the hand judiciously on the inside 
of the fore-arm, this fracture is easily ascertained by the de- 
pression in that part, from the inferior portion being drawn 
towards the radius by the action of the pronator radii quadratus. 
This derangement is in general less than that which takes place 
in fractures of the radius. The superior portion of the cubitus 
remains unmoved, as has been well observed by J. L. Petit. 

In this case the assistant who extends the parts, inclines the 
hand to the radial side of the fore-arm, the surgeon pushes the 
flesh between the two bones, and applies the apparatus last de- 
scribed. In all fractures of the bones of the fore-arm, and 
particularly in those which are near the head of the radius, a 
false anchylosis is to be apprehended, and should be guarded 
against by moving the elbow gently and frequently, when the 
consolidation is advanced to a certain degree. This precaution 
is more especially necessary in fractures of the olecranon. 



SECTION IV. 



Of Frablures of the Olecranon. 

This curved process, by which the cubitus is terminated su- 
periorly, its anterior surface being covered with cartilage, and 
its posterior having the tendon of the triceps brachialis inserted 
into it, is very analogous to the patella; and the resemblance 
would be perfect, if the latter, instead of being attached to 
the tibia by a strong ligament, were a continuation of its sub- 
stance, as the olecranon is of that of the cubitus. This simili- 
tude is still stronger in the fractures of these two bones ; so that 
what will be said on fractures of the patella, to which a long 
chapter shall be consigned, may be applied to those of the oler- 
cranon. 

These last-mentioned, which almost always take place at the 
base, and seldom at the summit of the olecranon may be ob- 
lique, but are more frequently transverse. They are occa- 
sioned sometimes by the contraction of the triceps brachialis, 
12 



<}0 OF FRACTURES OF THE OLECRANON. 

but more frequently by some external force, as by a- fall back- 
ward on the elbow. The fracture of the patella is, on the con- 
trary, more frequently produced by muscular contraction than; 
by an external cause. 

When the olecranon is detached from the cubitus by any 
cause, it is always drawn upward by the contraction of the tri- 
ceps braehialis, and the interval between it and the cubitus is 
perceptible to the touch or sight, and increases or diminishes by 
the flexion or extension of the fore-arm. The ascent of the seDa- 

t 

rated olecranon along the lower extremity of the humerus, may 
be more or less considerable: in all cases however, it ascends 
above the condyles, or lower tuberosities of the humerus. Fi- 
nally, the olecranon may be pushed by the fingers to one side 
or other, without any motion being communicated to the cu- 
bitus. 

Nothing can be easier than to distinguish by these marks a 
fracture of the olecranon, from a luxation of the cubitus back- 
ward, with which, however, it has been confounded. It is true, 
that when the fracture has been occasioned by an extremely 
violent cause, the contusion and inflammatory swelling may 
be so great as to render the diagnosis difficult, if not impossi- 
ble. But this uncertainty should not influence the treatment,, 
whieh must be directed first against the inflammation, whether 
the fracture exist or not. When the inflammation and its con- 
comitant symptoms have been allayed by blood-letting, the use 
of emollients and other such means, the discovery of the frac- 
ture will be easy; and if it be found to exist, it is to be treated 
in the following manner. 

The divided parts are brought into contact, by extending the 
fore-arm, and pushing down the olecranon from the place to 
whieh. k had been drawn by the contraction of the triceps. 
The principal- object is to counteract the action of this muscle, 
which tends incessantly to separate the detached olecranon from 
the cubitus. To effect this purpose, a circular bandage, mode- 
rately broad, is passed on the fore arm, fully extended; this 
being done the olecranon is pushed down into contact with the 
cubitus, and the middle part of a long compress placed behind 
it, the extremities- of which are brought downward and cros- 
sed on the anterior part of the fore-arm; after which several 
turns of the bandage made so as to cross one another, are car- 
ried round the articulation of the elbow. The bandage should 
then be roiled up on the humerus, in order to diminish, by* 
pressure, the irritability of the triceps brachialis, which is re- 



OF FRACTURES OF THE OLECRANON. QJ 

taxed by the extension of the fore-arm. This bandage being 
applied, the bend of the fore-arm is filled with lint, and a long 
splint applied on it anteriorly, by which the flexion of the arm 
is prevented. This splint is fixed by the same bandage, rolled 
on downward from the shoulder to the wrist, and upward 
again if the bandage be long enough. The oblique casts of 
the bandage, which cross one another on the articulation, form- 
ing a kind of a figure of 8, ought to be nicely applied, and 
drawn very tight; because if but slightly braced, their action, 
which is oblique, will not be sufficient to confine the olecranon 
to its situation. Previous to the application of these oblique 
casts, the skin of the olecranon should be drawn up by an as*, 
sistant; for, if this precaution be not taken, it may sink be- 
tween the divided portions and prevent their contact:. 

Though the contact be exact immediately after the applica- 
tion of the bandage, yet if, as is apt to happen, the bandage 
become relaxed, or if the patient inadvertently contract the 
trieeps, the olecranon ascends, because the bandage, acting per- 
pendicularly to its direction, can but feebly oppose the ascent 
of this process. An interval will therefore exist between the 
cubitus and olecranon, which will be filled up by granulations, 
and by the thickening of the periosteum, or tendinous expan- 
sion of the triceps which covers that bone; and the reunion of 
the parts will be effected by means of an intermediate ligamen- 
tous substance, the length of which will depend on the careful 
application and frequent renewal of the bandage. 

To this cause as Camper supposed, is to be attributed the 
impossibility of obtaining an immediate reunion of the olecra- 
non to the cubitus, and not to a defect of periosteum, or hu- 
mectation of the parts by synovia, as sonae authors have 
thought. 

We state the grounds of our opinion on this subject in treat- 
ing of fractures of the neck of the humerus, and of the patella. 
In forty or forty-five days the ligamentous substance acquires 
its greatest consistence, but the articulation should not be kept 
motionless so long; gentle motion may be commenced on the 
twenty-fifty or thirtieth day. The object of these motions is to 
prevent a false anchylosis of the articulation, not, as David 
thought by preventing the growth of inequalities or asperities 
on the callus but by facilitating the absorption of the inspissa- 
ted fluids accumulated about the part ; by stimulating the secre- 
tion of synovia, and exciting the irritability of the muscles, 
benumbed by long inactivity. 



92 OF FRACTURES OF THE OLECRANON. 

In cases of recovery obtained by these means, the olecranon 
adheres to the cubitus firmly enough to transmit to it the ac- 
tion of the triceps muscle, and to moderate the extension of 
the fore-arm. 

Compound fracture of the olecranon is an accident of the 
most grievous nature on account of the great number of nerves 
which pass in the neighbourhood of that part; it should there- 
fore be treated with the greatest care: the inflammatory symp- 
toms are to be combated by copious and repeated bleedings; 
the arm is to be placed half bent on a pillow, and dressed with 
Scuitets bandage. In these cases the intermediate ligamentous 
substance is always longer than in simple fracture, and, conse- 
quently, the force of the arm is much diminished. If a false 
anchylosis be prevented by judiciously exercising the articula- 
tion as soon as the state of the parts will permit, the patient 
may think himself fortunate. 

If the inflammatory swelling, &c. be not dissipated before 
the twenty-fifth, or twenty-sixth day, the application of the ap- 
paratus we have described will be useless, because it will be ne- 
cessary, at that time, to begin to exercise the articulation, the 
formation of the ligamentous substance being then considerably 
advanced, 



93 



CHAPTER XII. 



OF FRACTURES OF THE BONES OF THE HAND. 



SECTION I. 



Of FraSlures of the Bones of the Carpus. 

THE eight small bones which, placed in two rows, com- 
pose this part of the hand, are susceptible only of com- 
minutive fracture. Their smallness, and spongy texture, do 
not admit of their being fractured but by a cause which acts 
on them immediately \ and, in fact, fractures of them are al- 
ways occasioned either by a gun-shot wound, or some very 
heavy body falling on the hand. It is obvious that in cases of 
this nature, more attention is to be paid to the state of the 
soft parts than to the fracture. It often happens, that fractures 
of these bones render amputation at the articulation of the 
wrist necessary, or even that of the fore-arm. 



SECTION II. 



Of FraBures of the Bones of the Metacarpus, 

Fractures of these bones are rare, because any impulse re- 
ceived by the hand is divided between all these bones. That 
which supports the thumb, and which is unconnected with the 
Others, would be frequently fractured, if its mobility did hot 
secure it against that accident. 

These fractures are always the result of a force immediately 
applied j for the length of the metacarpal bones, though ranged 



94- FRACTURES OF THE METACARPUS. 

in the class of long bones, so little exceeds their other dimen- 
sions, that it can never happen that a force acting on their ex- 
tremities can break them about their middle part. If the hand 
be very forcibly pressed between two bodies, or if a heavy bo- 
dy fall on it, comminutive fracture will be the result; and al- 
most always several of these bones are fractured at once. The 
following ease, however, furnishes an example of a fracture of 
one of them. An armourer proving some muskets, made use 
of an iron ram-rod for setting fire to the priming: the musket 
was forced back by the explosion, and the iron rod thrust into 
his hand, so as to project on the other side, and raise up the 
integuments. The rod was drawn out, and the wound dressed 
with lint and emollient poultices; and on the fourth day the 
patient complained of excessive pain, when he attempted to 
bend the fourth or ring finger. On examining the part with 
care, and pressing the fourth bone of the metacarpus, it was 
found by the crepitation and motion, that that bone was frac- 
tured. Two long compresses were applied, one to the palm 
and the other to the back of the hand, both corresponding 
to the fractured bone: over these were placed splints, which 
extended to the extremity of the finger. A bandage was then 
rolled round the hand and three last fingers. The suffering of 
the patient ceased immediately on the application of this band- 
age, and his recovery was complete in six weeks. Comminu- 
tive fracture of these bones, as well as that of the carpus, fre- 
quently renders amputation necessary. 



SECTION III. 



Of FraBures of the Phalanges of the Fingers. 

Fractures of these bones being uniformly the effect of the 
immediate action of the cause, are always attended with more 
or less contusion. The alteration in the form of the finger, 
the motion of the broken pieces, and die crepitation occasion- 
ed by it, leave no doubt as to the existence of the fracture. 

The longitudinal derangement of a fractured phalanx is ve- 
ry difficult; and, in fact, that in the horizontal direction is 
almost the only one observed : it is effected by the flexor 
tendons, which draw the inferior portion to their side. The 



FRACTURES OF THE FINGERS. 95 

broken pieces may be brought into their proper situation, by 
pulling by the extremity of the finger, whilst the hand is fixed 
by an assistant. A circular bandage, moistened with a solu- 
tion of acetate of lead, is then rolled round the finger, and 
over that are placed four splints of thin wood or pasteboard, 
which are fixed on by the same bandage i the whole dressing 
is completed by including the two adjacent fingers in the last 
turns of the bandage. 

Fractures of these bones are generally united in twenty-five 
or thirty days, but the finger continues a little stiff for about 
two months, at the end of which time the stiffness entirely 
vanishes. 

When a very heavy body has crushed the extremities of the 
fingers, or when they have been bruised by a folding door, the 
soft parts are generally lacerated, the nail torn off, and the last 
phalanx fractured and denudated. If in such cases the parts 
hold together by a shred of a certain thickness, and which con- 
tains vessels enough for the nourishment of the phalanx, the 
reunion of the parts should be attempted. The prospect of 
success, it is true, is not great in most cases; but if our en- 
deavours to save the finger fail, amputation is still as much in 
our power as in the commencement. 

If the last phalanx alone is crushed, it will be better to am- 
putate at once, than attempt to save the joint. The cure would 
be tedious and difficult, on account of the exfoliation that 
would take place. Besides, the part being deformed, instead 
of being useful would be troublesome. By amputating at the 
articulation with the second phalanx, a simple wound is substi- 
tuted to the lacerated and ragged wound produced by the cause 
of the fracture. This will heal in a very short time, if care- 
be taken to preserve a sufficiency of skin to cover the surface 
©f the articulation, 



9 6 



CHAPTER XIII. 



OF FRACTURES OF THE THIGH. 

WHAT has been said of the treatment of fractures in 
general, in the first chapter of" this work, is more 
especially applicable to those of this bone than to any other. 
The femur is much exposed to fracture from the nature of its 
functions, its length and direction; and notwithstanding the 
great depth of soft parts by which it is covered, yet it is fre- 
quently fractured. 

It may be fractured in any point of its length, near the mid- 
dle or either extremity. We shall devote a particular chapter 
to fractures of its superior extremity, or neck} but, besides 
these last mentioned, there is another species of fracture, 
which consists in the separation of the great trochanter from 
the body of the femur. In the fractures of the lower extre- 
mity of the femur, not only one of the condyles may be sepa- 
rated longitudinally from the rest of the bone, but both con- 
dyles may, at the same time, be separated one from the other, 
and from the rest of the bone. All varieties of simple or 
compound fracture may be observed in those of the femur. — 
They may be produced in any part of it by a cause acting im- 
mediately on that part, or by a force acting on its extremities, 
which will probably produce a fracture of the middle part, 
where the bone is naturally bent: a fracture; produced by any 
of these causes, may be transverse or oblique. 

Derangement of the fractured portions is a uniform conco- 
mitant of fractures of the thigh; it may take place in any of 
the four directions already repeatedly mentioned, but that 
most frequently observed is the longitudinal derangement by 
which the limb is shortened. The numerous muscles of the 
thigh, by means of which derangement may be effected, are 
divisible into three classes, relative to the manner in which 
they tend or contribute to effect it. The three portions of the 
triceps femoris are attached to both pieces, and tend to produce 
the angular derangement by drawing the two fractured por- 



OF FRACTURES OF THE THIGH. 97 

dons to a salient angle on the outside, where their fibres are 
the strongest and most numerous. The biceps femoris, semi- 
tendinosus, semimembranosus, sartorius, rectus internus, and 
third adductor, all those, in short, which extend from the pel- 
vis to the inferior portion, or to the leg with which it articu- 
lates, tend to draw the inferior portion upward, on the internal 
side of the superior, the extremity of which forms a tumour 
on the external side of the thigh. The inferior portion is that 
which is always displaced, except when the fracture takes place 
immediately under the small trochanter, to which process are 
attached, by a common insertion, the psoas and illiacus muscles j 
which muscles would, in such a case, draw the superior portion 
upward and forward, producing by that means a tumour in 
the groin. 

When the femur is fractured immediately above the con- 
dyles, the inferior piece is drawn backward, and its superior 
surface turned downward by the action of the gastrocnemius 
externus, plantaris, and popliteus muscles. When the great 
trochanter is detached from the rest of the bone, it is drawn 
upward by the muscles which are inserted into it, but without 
producing any change in the direction or form of the thigh. 

The angular derangement in which the foot inclines either 
inward or outward, is the effect of the weight of the foot, or 
of the bed-clothes, rather than of muscular contraction. It 
shall be mentioned more particularly in treating of fractures of 
the neck of the femur. 

Deformity and diminution of the length of the limb, a 
change in its direction, the tumour occasioned by the deranged 
portions of the broken bone, the impossibility of performing the 
ordinary motions, the acute pain and crepitation produced by 
the motion of the broken pieces one on the other, indicate a 
fracture of the femur in such a marked manner, that it is im- 
possible to mistake it. Fractures of the thigh are, cMeris pari- 
bus, more 'dangerous than those of any other of our limbs, on 
account of the difficulty of keeping the pieces in a proper si- 
tuation. The ancients considered a fracture of the femur dif- 
ficult to be cured without a shortening of the limb; but at 
present the possibility of cure without any change or deformi- 
ty is attested by numerous instances. It is to be remarked, 
however, that more unremitting care and attention is necessa- 
ry in fractures of this bone, than in those of any other. 
13 



C)8 OF FRACTURES OF THE THIGH. 

We snail point out, at some length, the objects to which 
the attention is to be particularly directed in the treatment of 
these fractures. 

The bed in which the patient is to lie should not exceed 
three feet in breadth; a broader bed would render the raising 
and re-application of the apparatus very troublesome. It should 
have no foot-board, otherwise the assistant, whose duty it is 
to make the extension, could not conveniently draw the leg in 
the proper direction. Instead of a bed of down or feathers, a 
hair mattress should be used, which will not allow the limb, the 
weight of which is augmented bv the apparatus, to sink. If 
mattresses of wool are the only bedding to be found, their so- 
lidity should be increased by placing between them thin elastic 
boards. The head of the patient should repose on a simple 
pillow, the horizontal position being one of the desiderata. 
"When the head is too much raised by pillows, &c. the body 
tends to descend, and deformity of the limb will be the conse- 
quence, whatever attention may be paid in other respects. 

These particulars relative to the bed being punctually attend- 
ed to, an apparatus, as follows, is in the next place to be pre- 
pared: First, as many bandages, of three fingers breadth each, 
as will be sufficient to cover the leg and thigh, and which will 
form what has been already described under the name of Scul- 
tet's bandage: secondly, a number of long compresses, wet 
with some resolvent liquid, which are placed on such parts of 
the limb as appear most inflamed: thirdly, a splint-cloth, or 
fanon, in which the two lateral splints are rolled: the splints 
should be long enough to extend externally, fronTthe ridge of 
the os ilium, and internally, from the articulation of the fe- 
mur to a few inches beyond the sole of the foot ; and anteri- 
orly from the groin, or anterior side of the articulation of the 
femur with the bones of the pelvis, to the instep: fourthly, three 
bags of chaff, by means of which the sides of the thigh may be 
rendered parallel with the splints: fifthly, and finally, five strings 
or ribbands, by which the rest of the apparatus are to be secured 
externally: two are' to be placed on the thigh, two on the leg, 
and one is to be crossed on the instep and sole of the foot, and 
its ends made fast to the internal and external splints, in order 
to prevent the vacillation of the foot. 

Some practitioners apply Scultet's bandage on the thigh only, 
and do not extend it to the leg, nor envelope the foot in long 
compresses, drawn moderately tight; in consequence of which 
neglect, the leg and foot are apt to swell, from the return o£. 



OF FRACTURES OF THE THIGH. 99 

the fluids being impeded by the compression of the bandage on 
the thigh. 

This apparatus should be extended on the bed on which the 
patient is to be laid, in the order of their application; that is, 
first the strings or ribbands; next the fanott or splint-cloth; and 
over that Scultet's bandage, of which the different parts should 
partially cover one another; and last of all, the compresses. 
The patient, if dressed, is to be undressed very gently, and 
the fractured limb is to be moved as little as possible. In con- 
veying the patient to the bed on which he is to lie during the 
treatment, the surgeon himself ought to support the fractured 
limb, and place it exactly on the middle of the apparatus. The 
setting is in the next place to be proceeded to; to effect: which, 
the strongest of the assistants renders the pelvis immoveable, by 
pressing on the anterior and superior processes of the ossa ilia, 
whilst another assistant seizes the foot with both hands, the 
thumbs applied to the sole, and the fingers crossed on the up- 
per part, and draws it with a gradual effort, first obliquely 
outward, and then quickly in its natural direction : the surgeon 
placed on the external side, performs the coaptation; but the 
great depth of integuments renders this part of the operation 
almost entirely useless. 

The natural form and length of the limb being restored, the 
assistants continue the extension and counter extension, while 
the surgeon applies the different parts of the apparatus in the 
order already described, rolling compresses on the thigh and leg, 
and commencing the application of Scultet's bandage from the 
lower extremity of the leg, and proceeding upward. The splints 
rolled up in the cloth, are placed perpendicularly on their edges, 
at a small distance from the leg, in which interval bags of chaff 
are to be placed, and, on the chaff being pushed into the dif- 
ferent depressions, so as to equalize the surface of the limb, and 
provide for the equable pressure of the splints, these latter are 
pressed against the limb by the hands of an assistant, while the 
surgeon ties on the strings, by commencing with the one at the 
middle part of the thigh. The fillet crossed on the foot, and 
tied to the extremities of the lateral splints, is the last applied. 

It may be necessary to bleed the patient once or twice, and to 
confine him to the antiphlogistic regimen for four or five days, 
at the end of which time no disagreeable consequences are to be 
apprehended. If the pain and suffering of the patient be not 
excessive, the apparatus need not be raised for the first three 
or four days, but this measure should not be deferred beyond 



IOO OF FRACTURES OF THE THIGH. 

that time; for, however well the fracture may have been set, 
and however well and permanently the apparatus may appear to 
have been applied, yet it is possible that the pieces of bone may 
have been displaced by the action of the muscles. By neglect- 
ing this precaution, and raising the apparatus only every eight 
days, the fractured portions have passed one another, and con- 
solidated in that situation, and a lameness has been produced, 
which could never be remedied. At the end of about forty-five 
days, when, after having reapplied the apparatus eight or nine 
times, the callus is found so far formed as to bear the motion 
of the whole member, Scultet's bandage is to be taken off, 
and a simple roller substituted in its stead, capable of compres- 
sing the soft parts, and of preventing the cedematous swelling 
likely to take place. 

The foregoing mode of treating fractures of the femur, and 
which is effectual when they are transverse, is of little or no 
effect in cases of oblique fracture, which was supposed by the 
ancients to produce necessarily a shortening of the limb. In 
order to prevent this continued extension, the mechanism of 
which shall be explained in the chapter on fractures of the neck 
of the femur, has been employed by the moderns. 

If a very young child, as for instance, one of two or three 
years, is to be treated for a fracture of the thigh, a roller of 
one piece may be employed instead of Scultet's bandage. Four 
elastic wooden splints should be applied on the opposite sides of 
the limb, and secured by the circular bandage, a part of which 
has been already applied. It is not necessary, in this case that 
the splints should be longer than the limb, because the foot, at 
that age, bears a less proportion to the rest of the member, than 
at a more advanced period, and is not weighty enough to draw 
the limb to either side with it. The principal reason for pre- 
ferring the circular bandage in the case of children, is the dif- 
ficulty of re-applying the other apparatus every day, or as often 
as it may be soiled by the urine and fasces : it will be necessary, 
for the same reason to roll up the whole limb, after the appara- 
tus has been applied, in several folds of a strong linen cloth, 
which should be renewed every day. This is the only case in 
which Scultet's bandage is not to be preferred to any other. 

When the femur is fractured near the condyles, it will be 
necessary to stuff the hollow of the ham with lint, in order to 
prevent the lower fractured portion from being drawn back by 
the action of the muscles attached to it : if this derangement be 
not guarded against, the popliteal nerves and vessels may be 



OF FRACTURES OF THE THICH. IOI 

wounded by the protrusion of the fractured end of the bone, 
and the worst consequences may ensue. 

If the great trochanter be separated from the rest of the 
bone, the middle part of a long compress is to be applied on 
that process, and its extremities drawn downward and inward ; 
over which compress a spica bandage for the groin is to be ap- 
plied. 

More time is necessary for the consolidation of fractures of 
the femur, than for those of any other long bone, on account 
of the great compactness of its texture, particularly near its 
middle part. For this reason it is in general necessary to con- 
tinue the apparatus applied for fifty days, and sometimes for 
even a longer time. 

If the consolidation be very tedious, a stiffness in the articu- 
lation of the knee will be a necessary consequence*, and, if the 
fracture be so near the condyles as that the swelling and ob- 
struction may extend to the articulation, this consequence wilL 
be inevitable, and very difficult to remove. 

It would be superfluous to repeat here, respecting compound 
fractures of the femur, what has been already said on this sub- 
ject in the first chapter, and frequently repeated by particular 
applications. We shall therefore without further delay, pro- 
ceed to consider the fractures of the neck of the femur. 



102 



CHAPTER XIV. 



OF FRACTURES OF THE NECK OF THE FEMUR, 



THE neck of the femur may be fractured in any point of 
its extent. The fracture, however, most frequently takes 
place in its middle part, and more generally towards or at its 
base, than at its union with the head of the femur, although 
its base is its thickest part. These fractures exist strictly speak- 
ing, within the articulation; the orbicular ligament of which 
adheres to the lower portion of the bone, the superior having 
no connexion with the rest of the body, but by the round liga- 
ment; except, however, the case in which the ligament re- 
flected round the neck is not entirely ruptured. These fractures 
are almost always transverse; the reason of which is found in 
the spongy texture of the bone. In many cases the surfaces of 
the divided bone are very unequal, the one being marked with 
asperities or eminences, and the other with corresponding de- 
pressions. 

There is another species of variety of this fracture which takes 
place outside the articulation, near the union of the bone with 
its trochanters, and sometimes between these two eminences, 
the greater of which adheres then to the superior portion. 
There have been so many instances of fractures of this nature, 
that all are now agreed as to the possibility of their taking 
place. 

A member of the ci-devant Academy of Surgery fell on the 
great trochanter; the extremity of this side became shorter 
than that of the opposite, the foot and the knee inclined out- 
ward, and in short, all the symptoms of fracture of the neck of 
the femur were manifest, and the existence of such a fracture 
was agreed on «by a number of his brother surgeons. The frac- 
ture was treated in the ordinary way, and a cure was obtained, 
but not without a shortness of the limb. This person died short- 
ly after from another disease; his body was opened, and the 



OF FRACTURES OF THE FEMUR. IOJ 

articulation of the thigh examined, when it was found that the 
fracture had taken place below the insertion of the orbicular li- 
gament. I am indebted for this case to Citizen Lesne, a dis- 
tinguished member of the Academy, and editor of the Posthu- 
mous Works of J. L. Petit. Citizen Boyer has met several cases 
of a similar kind. 

I have seen a remarkable case of a shortened inferior extre- 
mity, in an old man, who died in the hospital of La Charite, 
in the year seven. A double fracture was found, one inside and 
one outside the orbicular ligament ; the latter between the two 
trochanters, the larger of which was separated from the rest of 
the bone. Although the patient was eighty three years of age, 
yet the consolidation had commenced. 

Fracture of the neck of the femur, generally simple, is some- 
times complicated with that of the great trochanter, very rarely 
with contusion, because the force which produces it does not 
act immediately on the part. Protected by a great depth of 
soft parts, and by the great trochanter, the neck of the femur 
is seldom fractured comminutively. That might however take 
place from a gun-shot wound; but as in that case the bones of 
the pelvis must also be fractured, and the parts contained in it 
injured : the fracture of the neck of the femur is but the slight- 
est part of the affection. 

Amongst the various fractures of the neck of the femur ought 
to be enumerated the decollation of the epiphysis, which, 
though rare, has yet been observed. Pare* mentions the pos- 
sibility of this decollation, allows that its diagnosis is extremely 
obscure, and assures us at the same time, that it has been often 
mistaken by very expert surgeons for a luxation. Young per- 
sons only are subject to this accident, because it cannot take 
place when the cartilage which unites the neck to the bone is 
ossified. 

The superior extremity of the femur is entirely cartilaginous 
in the new-born infant-, but soon after birth three points of ossi- 
fication may be observed in it, one corresponding to the head of 
that bone, and the two others to the trochanters. These osse- 
ous points gradually spread, the cartilage diminishes, and at 
length entirely disappears; but the ossification of the head and 
neck is much slower than that of the trochanters ; nor does the- 
cartilage of these parts totally disappear before the eighteenth 
or twentieth year. 

# Works of Ambrose Pare, lib. 15. chap. at. 



104 OF FRACTURES OF THE FEMUR. 

It is easy to conceive that an accident, which at a more ad- 
vanced period of life would produce fracture of the neck of 
the femur, will with more facility separate the head before the 
age of eighteen or twenty. It may even happen that a force 
which does not produce this decollation, shall however, disor- 
ganize the cotyloid cavity, by impelling inward towards the 
pelvis the parts of the three bones of which that cavity is com- 
posed. Ludwig* has given a ease of this kind. When the 
head and neck of the femur are completely united, their point 
of union is seldom the situation of a fracture \ and, as Duver- 
ney remarks, decollation is then impossiblef . The symptoms of 
decollation differ little from those of fracture : the dull crepita- 
tion which has been given as a sign by J. L. Petit J, is by his own 
acknowledgement very equivocal. But this difficulty in form- 
ing a diagnosis is of no great consequence, as the treatment 
does not differ from that of fracture of the neck of the femur ; 
nor is the prognosis more unfavourable, notwithstanding what 
Columbus^, arguing from the difficulty of setting the divided 
portions with acuracy, says to the contrary. 

Predisposing Causes.— Brittleness of the bones, as well as the 
vices of the constitution on which it depends, has been already 
given as a predisposing cause of fracture. Caries may be look- 
ed on as a predisposing cause of fracture of the neck of the fe- 
mur, by its destroying a part of the substance of the femur; 
but as in this case artificial means can have no effect in produ- 
cing a consolidation of the fracture, and as the caries will pro- 
bably occasion the patient's death, unless nature effect the union 
of the carious bone with some part of the pelvis, it seems use- 
less to give any further consideration to fractures, or division of 
the neck of the femur from this cause. Rickets, which some 
authors have mentioned as a predisposing cause of fracture, ra- 
ther prevents it by rendering the bones flexible. 

Duverney has given a case of a fracture of the neck of the 
femur, in which the venereal disease was evidently the predis- 
posing cause. But in cases arising from an internal cause, the 
removal of that cause is the principal object. 

Exciting Causes. — A fall on the great trochanter is the most 
frequent exciting cause *, and fracture of the neck of the femur 



* Dc Collo Femoiis ejusque Ffaftura Programma. Lipsiae. 
f Traite des Malad.es des Os, vol. i. chap. 8, art. z. 
X Ibid. vol. ii. 
§ De Re Anatomica. 



OF FRACTURES OF THE FEMUR. 105 

is so frequently a consequence of that accident, that when the 
one has taken place, the other is generally presumed. This ob- 
servation made by Citizen Sabatier* has been confirmed by ma- 
ny particular cases treated in the principal hospitals in Paris. A 
fall on the feet or knees sometimes occasions a fracture of the 
neck of the femur, in which case the weight of the body must 
be thrown more on one side than on the other. 

Let us examine the manner in which this fracture may be pro- 
duced. 

When a person falls on the great trochanter, the neck of the 
femur is acted on by that eminence which has a point d'appui on 
the ground, and by the body which acts immediately on the 
head of the femur. By this action and re-action, a force is ex- 
erted on the neck of the femur, which tends to make it paral- 
lel with the rest of the bone. By this tendency, that part of 
the bone is curved beyond its natural extensibility, and from 
the nature of the curve into which it is forced, its lower fibres 
break first, and so on successively to the superior, which break 
last; on the supposition that the rupture of these fibres was suc- 
cessive. In falling on the feet or knees, on the contrary, the 
tendency of the fracturing cause is to force the neck of the fe- 
mur to forma right angle with the bone; and the rupture of 
the fibres must of course commence in the superior. 

From this view of the mechanism of these fractures, it is evi- 
dent that they are never direct, that is, produced by a cause 
acting immediately on the part ; but that they are, on the con- 
trary, always the effect of a force communicated to that part 
by contre-coup or transmitted re-action, as has been observed by 
Davidf . The contusion which in general is but trifling in in- 
direct fractures, or those par contre-coup, may however be con- 
siderable in this case, when produced by a fall on the trochan- 
ter; for this reason, that, though the force be transmitted, yet, 
on account of the shortness of the neck of the femur, the frac- 
ture must take place near the part immediately affected; so 
that, with respect to contusion, fractures of this part may be 
considered as direct. 

Fractures of the neck of the femur are always attended with 
derangement: it is possible, however, that this derangement 
may not take place for a few days after the fracture. There 
are in the Memoirs of the Academy of Surgery, the particulars 

* Mem. de V Acad, de Chirurgie. 

f Prize-questions or" the Academy of Surgery, vol. iv. 

14 



106 0F FRACTURES OP THE FEMUR. 

of a case in which a man after having fractured the neck of 
the femur by a fall, was able to rise without any assistance, and 
walk home to his lodging. A similar case is found in Desault's 
Journal. Finally, a great number of cases collected by Louis, 
Duverney, Sabatier, and other authors of no less authority, 
and those observed by Citizen Boyer, leave no doubt on the 
possibility of a derangement ensuing several days after the 
fracture. And it is easy to conceive that in a fracture of what 
is properly called the neck of the femur, the orbicular ligament 
may oppose the derangement, and counteract the action of the 
powerful muscles, which pass from the pelvis to the lower frac- 
tured portion, into which, also, the orbicular ligament is in- 
serted. 

Another cause which must contribute to prevent derange- 
ment, is the projections and depressions of the surfaces of the 
pieces, which inequalities render lateral motion difficult. We 
have already remarked this circumstance, in treating of the di- 
rection of the fracture, which, accurately speaking, is neither 
oblique nor transverse. 

The fractures within the articulation are never attended with 
a very considerable derangement. The orbicular ligament yields 
a little without being tornj the body and neck of the bone, in- 
stead of their oblique or angular position becomes rectilinear \ 
from which change of direction, as well as from a slight de- 
rangement in the direction of the diameter, arises the shorten- 
ing of the limb. Louis has asserted that the derangement may 
be considerable, but has not supported this assertion either 
by facts or reasoning. In fractures outside the articulation, or 
between the trochanters, the muscles which tend to produce 
the derangement act without any opposition and draw the in- 
ferior fractured portion outward, upward, and a little back- 
ward toward the iliac depression. The great trochanter ap^ 
proaches the brim or ridge of the iliac bone, but never passes 
under the glutei muscles, which cover the surface of that 
bone. 

The action of the muscles which are inserted into the infe- 
rior portion, and particularly that of the glutei, is not the sole 
cause of the derangement j that effect being in part produced 
by the weight of the body, which forces the pelvis downward, 
and with it the superior portion of the femur: muscular action 
is however the principal cause. 

Besides the longitudinal derangement, that in the circum- 
ference also takes place in consequence of the rotation of the 



OF FRACTURES OF THE FEMUR. IO7 

whole inferior extremity outward. This is effected by the 
weight of the part, rather than by the action of the rotatory 
muscles. If the rotation of the limb were produced by the con- 
traction of these muscles, there would be more difficulty in 
bringing the foot to its natural position, or in inclining it in- 
ward, than in reality is found in bringing it in any of these di- 
rections. But in order to be fully convinced of the cause of 
this rotation, it is only necessary to observe the position which 
the inferior extremity assumes, when a person laid horizontally . 
on his back abandons it to its own weight: in such a case the 
foot and knee incline constantly outward. 

The derangement may take place internally, either by a par- 
ticular disposition of the extremity, by the pressure of the 
bed-clothes, or some such cause. Pare and Petit describe the 
derangement as having taken place internally, in all the cases 
of this kind that occurred to them. Louis has endeavoured to 
give a favourable turn to the report of Pare. He says that Pare 
meant merely to state that the foot was separated from the op- 
posite leg by a less interval than the knee of the same sidej 
which observation is true in a certain sense, even when both 
are turned outward. As to Petit we must either suppose that 
a deference for the opinion of Pare led him into an error of fact 
or expression, or that the mistake originated with the copyist 
or printer. But since the publication of Louis's explanation in 
the Memoirs of the Academy, the possibility of derangement 
inwards has been ascertained by observation. Desault conclu- 
ded from his experience that the rotatory derangement inward 
was to that outward as 1 : 4. 

Diagnosis. — The resemblance between the symptoms of this 
fracture and luxation, has frequently occasioned these two af- 
fections to be confounded with one another. Thus we find 
that luxation of the femur was known to the ancients, and that 
fracture of the neck of that bone was unknown until described 
by Pare. He is, at least the first author who has given any 
clear and positive information on that subject. Since his time, 
observations on the nature of this affection have been multipli- 
ed; but as yet authors are not agreed as to the symptoms by 
which it is distinguished. 

Fracture of the neck of the femur is so frequent a conse- 
quence of a fall on the great trochanter, that the former ha- 
ving taken place, renders the other highly probable: an acute 
pain felt in the articulation augments that probability. But the 
(ail or pain which may not exist even when the fracture has 



108 OF FRACTURES OF THE FEMUR. 

taken place, as in a case related by Duverney, are equivocal, 
or at best but corroborating circumstances. The sensible signs 
are those alone on which the diagnosis is to be founded : they 
are as follows: 

It sometimes happens, that in the moment of falling the pa- 
tient hears a crack in the articulation, and remains without the 
power of raising himself. Shortening of the limb is a conse- 
quence of this fracture; but as that does not always take place 
immediately, it cannot assist in forming the diagnosis in every 
case; but the uncertainty arising from the want of that sign is 
quickly removed, for the shortness supervenes in a few days. It 
may not be superfluous to remark, that in ascertaining the 
shortness of the limb, the patient should be laid supine on an 
horizontal plane, and the pelvis so placed as that its anterior 
and superior spinous processes may be in the same horizontal 
line. 

The point of the foot is turned outward, as is the knee, and 
the leg bent so as that the heel is turned inward, and placed be- 
hind the ankle of the other foot, in the depression between the 
ankle and tendo Achiliis. 

It very rarely happens that the heel is placed above the an- 
kle, except, however, when the fracture is outside the articur 
lation, and the longitudinal derangement very considerable. 
In fractures of the part strictly called the neck, it would be 
necessary, in order that the ankle should be so placed, that the 
fracture had been produced by a fail on the feet or knees from 
a great height, and that the orbicular ligament had been en- 
tirely torn, of which no example has as yet been observed. 

The limb may be brought to its natural length by means of 
extension and counter-extension, but it shortens again instant- 
ly if left to itself. The foot may, with great facility, be placed 
in its natural position, without causing in any degree the pain 
and suffering which Citizen Sabatier seems to have apprehend- 
ed; he says, that the attempt is imprudent, and the motion 
difficult. The asperities of the broken pieces can seldom irritate 
or lacerate the soft parts, because the orbicular ligament is sel- 
dom entirely torn: to that cause, however, Citizen Sabatier 
attributes the pain and difficulty, which he considers as being 
so formidable. 

In bringing the limb into its natural direction, the fractured 
surfaces are rubbed one against the other; and this friction, 
more or less considerable according to the asperity of the sur- 
faces, produces a crepitation, which is one of the surest signs 



OF FRACTURES OF THE FEMUR. JO9 

of fracture. It has been asserted by some writers, that the 
great depth of soft parts prevents the crepitation from being 
heard, which for that reason, say they, can be no sign of this 
fracture. But the clear and distinct perception of the noise is 
a better proof of its existence than any reasoning can be of its 
impossibility; and we assert, that it is possible in most cases to 
tear it. I have myself frequently heard it, by applying, it is 
true, a very attentive ear. 

In turning the limb, in order to place the foot straight, or 
to incline it inward, the great trochanter will be found, by 
placing the hand on it, to move in a very small space, or, as it 
were, on itself pivot-like. But in the rotation of the thigh 
in its natural state, that eminence describes an arch of a circle, 
the radius of which is composed of the length of the neck and 
head of the femur ; but after the fracture, the diameter of this 
circle is composed of the diameter of the bone and of that part 
of the neck which remains below the fracture. Whence we 
may conclude, that arches described by the great trochanter in 
cases of fracture of the neck of the femur, will be so much the 
greater, as the fracture takes place nearer the head, and that this 
arch will be at its maximum in the case of decollation of the 
epiphysis. In order to appreciate this sign it will be necessary 
to compare the arches described by the trochanter of the 
fractured member with those described by that of the opposite 
side. 

When the fracture is outside the articulation, the trochanter 
appears less, and is nearer the ridge of the ossa ilia than in the 
natural state. The buttock is also rounder than natural, on 
account of the relaxation of the muscles. 

Another sign of which authors have made no mention, but 
which is constant, is the impossibility of raising the member 
all at once; that is, of bending the thigh on the pelvis, the 
leg being extended on the thigh. It is necessary for the exe- 
cution of this motion, that the limb have a point d'appui in the 
acetabulum: it may be compared to the circular motion with 
which the hand is raised to the forehead, and which is imprac- 
ticable when the humerus has lost its point cF appui by a fracture 
of the clavicle. In attempting to raise the thigh, the patient 
first bends the leg analogously to the effort made to bring the 
hand to the forehead, by bending the fore-arm.* 

* It will always be easy to distinguish the Impossibility of this motion 
resulting from pain, from that resulting from tiie want of a point d^apfui 



IIO OF FRACTURES OF THE FEMUR. 

According to Louis, much pain is produced by moving the 
fractured limb from that of the opposite, and none at all by 
the contrary motion: this difference he attributes to the action 
of the lower fractured portion on the soft parts of the external 
side, and considers the pain caused thereby as a distinctive sign 
of the fracture. We have already said, that a derangement as 
considerable as that supposed by Louis never takes place. If it 
really did, adduction and abduction ought to be equally painful; 
and, in fact, every motion given the limb, no matter in what 
direction, causes more or less -pain; but pain, however produ- 
ced, is a very equivocal sign, as it belongs equally to all dis- 
eases of the articulation. 

Of all affections, there is none so easily confounded with 
the fracture of which we are treating as the different species 
of luxatidn of which the thigh is susceptible. The luxation 
upward and outward is the most easily mistaken for fracture, 
notwithstanding the two affections have in common only the 
shortening of the member. The impossibility of restoring the 
limb to its natural length by a gentle effort, its permanence in 
the natural situation when once restored, and, before that is 
done, the impossibility of turning the foot outward, which has 
Been carried inward, are signs by which that species of luxa- 
tion can be easily distinguished from fracture of the neck of 
the femur. 

In the luxation inward and upward, in which the head of 
the femur is propelled toward the pubis, the extremity is 
shortened, and the foot turned outward; neither of which cir- 
cumstances can be corrected without antecedently restoring the 
femur to its natural situation. 

Luxations downward, whether inward or outward, can ne- 
ver be mistaken for this fracture, because in these the member 
is always lengthened. 

The secondary, or spontaneous luxation of the femur, is al- 
ways preceded by dull pains felt in the superior and inferior arr 
ticulations of that bone; it is further characterized by a gradu- 
al elongation of the member, and then by a sudden shortening 
and a diminution in the interval which separates the great tro- 
chanter from the ridge of the iliac bone; by the inclination in- 
ward of the foot and knee; finally, by all the symptoms of lux- 
ation upward and outward, joined to the induration of the soft 

for the femur. This impossibility remaining after the inflammatory symp- 
toms have ceased, will always be a pathognomonic sign. 



OF FRACTURES OF THE FEMUR." Ill 

parts, the abscesses which form in these parts, and which ter- 
minate in fistulas. All these signs leave no possibility of its 
being mistaken for a fracture of the neck of the femur, an 
affection with which it has nothing in common, except indeed 
that the spontaneous luxation is sometimes produced by the 
same cause as the fracture, namely, a fall on the foot, knee, 
or great trochanter, by which the cartilages of the articulation 
are contused. The irritation caused by this contusion produces 
a turgescence and swelling of the cartilages and cellular tex- 
ture that accompanies the round ligament. This tumefaction 
augments until the acetabulum is entirely filled, and the head 
of the femur expelled from that cavity. 

It appears, then, that a strict comparison of the symptoms 
will enable the surgeon to distinguish a fracture of the neck of 
the femur from any affection of the hip joint. But we must 
acknowledge, on the other hand that fractures of this part of 
the femur, which are without any, or with very little derange- 
ment, are not always very easy to be ascertained or distinguish- 
ed. An old man fell on the great trochanter, and the length 
of the extremity of that side was found to have diminished 
half an inch in consequence of this fall ; but there was no other 
symptom of fracture. Citizen Boyer pronounced the existence 
of a fracture of the neck of the femur, and a second surgeon 
confirmed this decision. A third practitioner was not clearly 
of the same opinion; but remarked that the shortening might 
be owing to the contraction of the muscles; but as there was 
no symptom of that contraction which could not produce the 
shortening of the limb without nearly obliterating at the same 
time the interarticular cartilages, the apparatus for fracture was 
applied, because, whichever opinion tfas the true one, no in- 
convenience or evil could result from its application. The pa- 
tient died of an ascites in five days. On dissecting the articu- 
lation of the thigh, a fracture of the neck of the femur was 
found, and consolidation had commenced, though it had ad- 
vanced but very little. 

We shall recapitulate in a few words what distinguishes this 
fracture: a fall on the great, trochanter followed by pain in 
the articulation, with the impossibility of bending tbe thigh 
on the pelvis, the leg being extended on the thigh; shortness 
of the extremity, which is easily removed, but returns as soon 
as the extending force is discontinued; an inclination of the 
foot and knee outward, with great facility of moving these parrs 
to their natural situation; crepitation produced in effecting dif- 



112 OF FRACTURES OF THE FEMUR. 

ferent movements; and the smallness of the circle in which the 
great trochanter moves in a rotatory motion. We can seldom 
be mistaken as to the existence of this fracture, if we attend 
to all these circumstances. , 

When the want of any important symptom renders the 
case doubtful, the apparatus should however be applied, as no 
danger can result from its application, provided the inflamma- 
tory symptoms have disappeared. It generally happens that in 
a few days the shortening of the extremity removes any doubt 
that might have been entertained; and this shortening, as we 
have already mentioned, may be retarded by the mutual inser- 
tion of the fractured surfaces, or by the resistance of the orbi- 
cular ligament. 

The prognosis of fractures of the neck of the femur is very 
difficult to establish. Some authors consider them as highly 
dangerous, always occasioning inflammation of the cartilages 
and surrounding soft parts. Morgagni* has made some obser- 
vations, which tend to give weight to this unfavourable prog- 
nosis. Others, on the contrary, consider these disagreeable 
consequences as extremely rare, so much so as never to have 
met them in their practice. This we can say, that these frac- 
tures are never followed by secondary or spontaneous luxation 
of the femur, which proves that the contusion of the cartila- 
ges has not been excessive, and that probably the whole force 
was spent in effecting the fracture. 

The difference of opinion on the prognosis of this affection 
does not regard merely the inflammation and abscesses which 
it may occasion, and the fistulas which result from these ab- 
scesses. Some authors are of opinion, that the shortening of the 
limb can by no means be guarded against; and others, that the 
consolidation of the fracture cannot be at all effected. There 
are some, however, who affirm that the consolidation is ob- 
tained in this case as in any other. As the treatment must be 
accommodated to whichever of these opinions is adopted, it is 
necessary to consider carefully the greater or less probability 
of each, how far any of them may be true, and the restricti- 
ons which they may require; and to consider, in short, in what 
particulars they may serve to direct the treatment. By recur- 
ring to what we have already advanced on the formation of 
callus, and on the different theories on that subject, we shall 
acquire at once a solution of the problem. 

* Morgagni de Vausis et Sedibus Morb. Epist. 56. 



OF FRACTURES OF THE FEMUR, II J 

Thus those who have admitted the existence of an osseous 
humour from which the callus is formed, have argued, that 
fractures of the neck of the femur cannot be cured, because 
this osseous humour is perpetually diluted by the synovia, with 
whieh the broken ends must always be moistened. The par- 
tisans of Duhamel's opinion have given as a reason for the sup- 
posed non-eonsolidation of this fracture, the want of the pe- 
riosteum on that part. But, in fact, it is furnished with a pe- 
riosteum by the fibrous duplicature of the orbicular ligament 
which is reflected round it, and which, provided itself with 1 
very vascular texture, transmits to the bone the vessels that 
nourish it. But facts, which attest the possibility of eonsoh> 
dation, render it unnecessary to enter into any verbal refuta- 
tion of assertions and theories. Numerous instance-s of reco- 
very are related, and preparations which prove that consolida- 
tion had taken place, are to be met in many anatomical col- 
lections. The consolidation is, doubtless, slower and more 
difficult in this than in other parts, but the difference in the 
time necessary for cure may be easily accounted for by our 
theory of the formation of callus. 

The possibility of the consolidation of a fracture supposes 
that each of the broken portions is endued with a certain de- 
gree of vitality: the splinters of bone which, in comminutive 
fracture, are totally detached, never reunite. In fracture of 
the neck of the femur, the inferior portion is endued with all 
the conditions necessary to a prompt reunion; but the superior, 
on the contrary, enclosed entirely in the acetabulum, and in 
contact only with the cartilaginous surface of that cavity and 
with the orbicular ligament, has no connexion with the rest 
of the body, but by means of the round ligament which con- 
veys to it a few blood vessels, but which are not sufficient for 
giving its vascular texture the degree of turgescence necessary 
for the generation of callus. In most cases, the duplicature of 
the orbicular ligament, which we have already described, is 
but partially torn, and a communication between the vessels of 
the head of the femur, and those of the other parts, is pre- 
served, by means of which the consolidation is principally ef- 
fected. To the complete rupture of the orbicular ligament* 
ought probably to be attributed the non-eonsolidation of some 

* The motion Cofflmuriicated to the limb, in order to produce crepita- 
tion, always obscure, may aid in completing the rupture j for which rea- 
son the trial ought not ta be made without the greatest caution. 

15 



1 14 OF FRACTURES OF THE FEMtfR. 

cases of fracture. Old age is, however, the most frequent 
cause of non-consolidation: and those who are of opinion that 
the fracture of the neck of the femur is incurable, endeavour 
to support that opinion by instances of this kind in old persons. 
Ruisch cites many cases communicated to him by Gerard 
Borst, who was physician to an hospital of old women at Am- 
sterdam, in which a recovery could not be effected. In these 
persons great age was an invincible obstacle to the formation 
of the callus, and was the sole reason why, after death, the 
head of the J)one was found diminished, decayed, and con- 
verted into a kind of ligamentous cap. 

I dare say too, that the great hospitals of Paris destined for 
the reception of aged persons, as La Salpetriere and the Hos- 
pital of Invalids, could furnish instances of the same kind suf- 
ficient to warrant the induction that this fracture is incurable 
beyond a certain age, if not sufficient to lead into error by too 
general an application of particular facts. 

It is not in our power, however, to mark precisely the pe- 
riod beyond which a cure is not to be hoped for. To be able 
to settle this, it would be necessary that the effects of old age 
were uniform in every individual, and that the degree of se- 
nility were always commensurate with the number of years. — 
Lesne shewed, at the Academy of Surgery, the femur of a 
woman aged eighty-nine, with marks of a consolidated fracture 
of its neck. I have published the case of a man aged eighty- 
three, in whom the consolidation of a double fracture was con- 
siderably advanced. Numerous facts of this nature authorize 
and require the application of the apparatus in all cases, except 
where the patient, reduced to the last stage of decrepitude and 
debility, cannot support its weight, or is attacked by some 
mortal disease. But at the same time, the surgeon should, for 
his own sake, acquaint the patient and his friends with the un- 
certainty of the cure, in order to ward off any imputation 
that might be made in case of failure. 

Authors who have considered the consolidation as impossi- 
ble, have ascribed to that cause the shortening of the limb; 
whilst others, partisans of the opposite opinion, have however, 
considered the shortening and lameness as uniformly arising 
from the improper position of the fractured pieces; the lower 
of which, say they, slides on the superior, obeying the con- 
traction of the muscles which draw it upward, so that the 
fractured surfaces can no longer correspond exactly, and the 
member becomes necessarily shortened in proportion to the 



OF FRACTURES OF THE FEMUR. I J 5 

ascent of the inferior fractured portion, and diminution of the' 
obtuse angle formed by the neck of the femur with the body 
of that bone. Or it may happen that the fractured surfaces 
shall have no point of mutual contact; that the angle, from 
oblique, shall become right, or nearly so; and that the union 
shall be effected by means of a ligamento-cartiiaginous substance: 
a case of this kind has probably given rise to the opinion that 
the reunion of these fractures was analogous to that of the 
patella and olecranon. 

Fabricius Hildanus, Platner, Ludwig, &c. have positively 
asserted, that a recovery without shortening and lameness was 
impossible. L,ouis and Citizen Sabatier appear to have adopted 
the same opinion, which, however, is now known to be erro- 
neous from the success obtained in various cases. Of this suc- 
cess, Desault's practice furnishes many instances: from that of 
Citizen Boyer, which has been equally extensive and success- 
ful, I shall content myself with citing one example. 

A strong robust hackney-coachman fell from the box, and 
fractured the neck of the femur; the great trochanter having 
borne the reaction of the fall. The contusion was such as 
might be expected from the height of the fall and the person's 
weight. Four hours after the accident, when he was convey- 
ed to La Charite, on the 20th Prairial, 5th year, the swelling 
and tension were extreme. Emollient poultices were applied, 
bleeding and an antiphlogistic regimen were prescribed. The 
limb being but little shortened, afforded a ground of presuming 
that the fracture was within the articulation. On the subsiding 
of the inflammatory symptoms, the apparatus for making conti- 
nued extension was applied, and reapplied, as often as its relax- 
ation rendered it necessary. Gangrenous eschars were formed 
on the instep and tendo Achillis, although thiclc compresses 
were placed between these parts and the pieces of the appara- 
tus: it is possible, however, that they might have been pre- 
vented, had the patient, a man of uncommon firmness and 
courage, complained of the pressure being too great. The re- 
union was complete on the fiftieth day, as was proved by the 
motion of the whole limb: on the sixtieth day the patient 
quitted his bed, and walked about with crutches; and, at the 
end of three months, left the hospital perfectly recovered, 
there being then no perceptible difference in the length of his 
two inferior extremities. 

It is then established by what precedes, that a cure without 
lameness may be obtained, as well as a perfect consolidation, 



Il6 OF FRACTURES OF THE FEMUR. 

but by means, it is true, unknown till lately. It is not surpri- 

ng that surgeons, unacquainted with this means, supposed 
iruneness an inevitable consequence of fractures of the neck of 
the femur. 

The general causes which retard or prevent the formation of 
callus will affect fractures of the neck of the femur more than 
any other, because the formation of the callus is slower there 
than in any other part; for which reason every motion should 
be particularly avoided, as well as every other circumstance 
that might disturb the generation of callus. In this case more 
than in any other, a disposition to cancer, scurvy, &c. is un- 
favourable, and a state of general debility is also injurious; it 
should, therefore, be combated with extraordinary vigilance. 
Pregnancy, which we suppose to be in general of little or no 
effect, might, however, diminish the probability of a perfect 
consolidation of a fracture of the neck of the femur. 

The particular objects to which, in treating these fractures, 
we are to direct our attention, are no other than those already 
mentioned in general, namely, to set the bone, keep the 
pieces in their place, and combat any unfavourable symptom 
that may arise. The means of effecting extension and coun- 
ter-extension are the same as in other fractures of the femur, 
and for the same general reasons as mentioned in treating of 
the fracture of the body of that bone. If it be necessary to 
employ a great number of assistants, a cloth, on which each 
may pull, should be rolled on the inferior part of the leg, and 
two others round the pelvis; the extremities of one of which 
should be joined and held above the hip of the side affected, 
for the purpose of making counter-extension; whilst another 
should be brought in the opposite direction, and held by a suf- 
ficient number of assistants, in order to prevent the pelvis 
from being drawn to the fractured side. The joint action of 
these two last mentioned means of counter-extension is neces- 
sary to render the pelvis immovable. In most cases, however* 
this purpose is answered by simpler means. 

Previous to any attempt to remedy the longitudinal derange- 
ment by means of extension and counter-extension, it will 
be necessary to correct that of the circumference, by gi- 
ving the- foot its natural direction. Coaptation is a part of the 
operation totally useless in setting a fracture of the neck of the 
femur, on account of the greath depth of soft parts, and the 
total impossibility of acting on the superior piece of bone. 



OF FRACTURES OF THE FEMUR. I l~]. 

If on the first attempt to extend the limb, the muscles are 
found to contract powerfully, it will be useless to continue ef- 
forts painful and fruitless for the patient. The best practice to 
be adopted then, is to apply the apparatus for fractures of the 
body of the bone, draw some blood from the patient, put him 
on an antiphlogistic regimen, and wait the removal of the spas- 
modic state. This state is much less frequent in the fractures 
of the neck of the femur than in those of the body of that 
bone; because in the former the fractured ends are within the 
orbicular ligament, and cannot therefore irritate the soft parts. 
"When it was customary to apply the extending force above the 
knee, and the counter-extending to the groin, the spasmodic 
state was much more frequent than since the present improved 
practice has been adopted. 

The difficulty of keeping the pieces in their place in a frac- 
ture of the neck of the femur is inversely proportional to the 
facility with which the setting is effected-, for which reason the 
inefficacy of the ordinary means has been long ago acknow- 
ledged in oblique fractures of the body of that bone, as well as 
in fractures of its neck. Different expedients have been devi- 
sed at different periods, to remedy this disadvantage. We shall 
compare their merits, after first considering the position in 
which the limb should be placed. 

The half-bent state recommended by Pott for the inferior as 
well as superior extremity, is attended with a great number of 
inconveniences, the mention of some of which will suffice for 
its rejection; the facility with which the limb changes from 
that position, the difficulty of applying the apparatus, the im- 
possibility of comparing the length of the limb with that of the 
opposite side; finally, the pain produced by the continual 
pressure on the great trochanter, and the gangrene which en- 
sues. 

In fracture of the neck of the femur, as in all those of the 
inferior extremity, the leg should be extended on the thigh, 
and the thigh on the pelvis. This position must be secured by 
means of an apparatus, on the invention of which the imagi- 
nation of practitioners and theorists has been very active. The 
expedients for effecting this are so numerous, that a descrip- 
tion of them would lead us too far from our object. Studious to 
avoid any superfluous details, and equally so any important omis- 
sion, we shall range, in two classes, the different apparatus: in 
the first, those which do not effect any extension; in the se- 
cond, those which do. 



11$ * OF FRACTURES OF THE FEMUR. 

Several authors have recommended the spica bandage of the 
groin, composed of a piece of linen cloth, of a considerable 
breadth, and long enough to be rolled round the pelvis several 
times. This bandage being rolled up in one, is drawn three or 
four times round the pelvis, and then several times obliquely 
#n the superior part of the thigh, by directing it towards the 
great trochanter, thence round the body, and so successively; 
but instead of fixing the fractured portions, it contributes to 
derange them. As much of it as is applied on the pelvis, is ab- 
solutely useless j and the oblique casts, upward and outward, 
can have no other effect than that of deranging the lower por- 
tion of bone; that is, of causing its ascent to the external iliac 
depression. Finally, the application of the spica requires that 
the limb be supported and raised up from the bed, which can- 
not be done without disturbing the generation of the callus. 
This objection is of the greatest importance, because the spica 
requires to be frequently renewed, as it relaxes quickly, and is 
soon soiled with the patient's urine and faces. 

The eighteen -tailed bandage, and the fanons or faux-fanom 
with which it is assisted, act only on the inferior portion of bone, 
yield like it to the causes of derangement, andean therefore be 
of no utility. And even though this bandage should act on 
both the fractured portions, it is now well ascertained, that 
bandages, whatever may be their construction, can contribute 
but very little to the confining of pieces of a broken bone ; and 
that, relatively to that object, the effect of this as well as cf the 
others, is absolutely null. As to the fanons or fa ux-j h nens, their 
circular shape admits them to act only by single paints, or a 
single line of contact; for which reason their effect can be but 
very trifling. Besides, if the bands by which they are secured 
be drawn tight, they will necessarily be displaced by sliding 
backward or forward. 

Others have employed long splints, of which the external 
ascended on the ribs, and the anterior on the abdomen; both 
of which, and the internal splint, extended beyond the foot. 
The depressions were filled with some kind of stuffing, in or- 
der to procure an equable pressure; and the splints were kept 
applied to the limb by ribbands or tape, and secured at their su- 
perior extremities by a roller passed round the trunk, the im- 
mobility of which, with respect to the limb, was one of the 
objects proposed. But this immobility of the body could not 
prevent the glutei muscles, as well as all the others, which ex- 
tend from the pelvis to the femur or leg, from drawing the in- 



OF FRACTURES OF THE FEMUR. II9 

ferior portion of the femur upward and outward •, for which 
reason this means has been abandoned, though it has, over the 
two preceding, the advantage of correcting the derangement 
in the circumference. Dalechamp hit on the expedient of 
fastening the leg to the foot of the bed ; but as the body was 
not fixed, it slipped down and rendered this precaution useless. 
To these may still be added, the tin trough, lined with fustian, 
invented by Fabricius Hildanus, and in which the outside of 
the thigh was placed, the oblique bandages, and all that as- 
semblage of petty contrivances heaped on the limb by Duver- 
ney. Ail these expedients act only on the inferior portion of 
the femur, yield to all the causes that move it, and can in no 
manner oppose the shortening of the extremity. 

There remains another method which demands a more par- 
ticular notice. It was proposed by Foubert, adopted by Louis 
and Citizen Sabatier, and approved of by the Academy of Sur- 
gery. This method was for some time looked on as the most 
effectual for the treatment of fractures of the neck of the 
femur. 

The fracture being set according to the rules prescribed, and 
compresses, impregnated with a resolvent liquid, applied to the 
articulation; the thigh and leg are fixed by means of fanons y 
and the foot by means of a slipper or sole. The inferior por- 
tion of the femur is in a very short time drawn outward and up- 
ward by the contraction of the muscles. This derangement, 
foreseen by the inventor of the method, is remedied by reset- 
ting the fracture every day, and reapplying the apparatus. From 
the fifteenth to the twentieth day, the derangement becomes 
less frequent, and the part less irritable; for which reason there 
is less muscular contraction. After the twenty-fifth, the re- 
setting is no more necessary, the limb is allowed to rest, and the 
fanons are kept employed, tightening them as often as they re- 
lax, for three months and a half, at which time the apparatus 
may be totally removed. This invention, originally suggested 
by Ambrose Pare, does not merit all the encomiums which 
have been bestowed upon it. Nothing can more effectually re- 
tard, or even prevent the formation of the callus, than the 
motions communicated to the limb, at the very time that na- 
ture is most actively employed in generating it. 

In order to keep, in fractures of the neck of the femur, the 
pieces in their proper situation, it is necessary that some cause 
counteracts that which tends to produce their derangement. 
This latter acts by drawing upward and outward the inferior 



120 OF FRACTURES OF THE FEMUR. 

portion, making it ascend on the external side of the superior, 
which is itself pushed downward by the weight of the pelvis 
and body. A further derangement is produced by the falling 
outward of the foot and knee: in order to prevent which, it 
has been proposed to tie the toes to those of the other foot. 
Brunninghausen used to fix the leg of the fractured side to that 
of the opposite, by means of a sort of stirrup, making, by this 
contrivance, the sound leg act as a splint; but these means 
serve merely to prevent the falling outward of the foot, but 
not at all the shortening of the limb. Besides, the position 
cannot be long persevered in, because fastening both legs to- 
gether, incommodes the patient very much. 

A continued extension is the only means of keeping down 
the lower portion of the femur, of opposing the descent of the 
superior, of counteracting the irritability of the muscles, and of 
producing a cure without lameness or deformity. We do not 
propose, as already remarked in the first chapter of this work, 
to overcome, by this means the strong and involuntary con- 
tractions of the muscles which immediately succeed the frac- 
ture, and which should be opposed by a moderate and gradual 
extending force. The application of the apparatus for making 
continued extension is not prudent, until the spasmodic state 
be completely removed. It is not intended that this apparatus 
shall preternaturally extend the muscular fibre, by drawing its 
extremities in opposite directions, but merely that it shall sup- 
ply the place of the bone, by opposing the contractile power 
naturally inherent in the fibre, and always tending to act. 

Almost all those who have acknowledged the indispensable 
necessity of continued extension, have invented different means 
for putting it into execution. Their respective merits can be 
appreciated by comparing their different ways of acting with 
the general rules already laid down for effecting this purpose. 

The bed of Hippocrates, and the Glossocomon used by the 
ancients, engraved in the Works of Pare, have been abandon- 
ed on account of their complication: they had no other advan- 
tage than that of acting in the direction of the fractured bone. 
By acting immediately on the fractured thigh, in effecting ex- 
tension and counter-extension, their action was limited to a 
small surface, and the limb lengthened abruptly. 

The method used by Avicenna, adopted by Petit, Heister, 
and Duverney*, who have somewhat modified it, consisted in 

* The greater part of authors recommend the vise of the spica, in addi- 
tion to the extension and counter-extension produced by this means. 



OF FRACTURES OF THE FEMUR. 121 

fastening to the head and foot of the bed, the bands with 
which the extension and counter-extension were to be effected. 
The superior were applied on the upper part of the thigh, and 
the inferior above the knee. 

Petit advises to place two bands at the same time, one above 
the knee and another above the ankle, to act alternately, so 
that when one becomes troublesome it may be relaxed and the 
other used, 

Besides the unsteadiness of the band placed above the knee, 
and the irritation of the muscles occasioned by it; this method 
has still further the disadvantage of the thigh and pelvis not 
being so fixed by it as to constitute one piece; without which 
essential condition, the superior portion of the femur yields to 
all the motions of the pelvis, with which it is connected. The 
loosening of the bands, which is frequent in proportion to their 
length, is another objection which decides the absolute insuffi- 
ciency of this method. In confirmation of this opinion, "We 
may quote the testimony of the Arabians themselves, invent- 
ors of this method, who used it in every case of fracture of 
the femur, whatever might be its direction, but who acknow- 
ledge that the cure was seldom effected without a lameness. 

Others have endeavoured to the effect extension, by means 
of a band applied above the ankle, and which, passed over a 
pully, had a weight suspended from the other extremity. The 
pully was so disposed, as that the weight acted in the direction 
of the fractured bone, which joined to the advantage of acting 
on the leg, produced a well directed extension : this, however, 
was rendered useless on account of there being no counter-ex- 
tension, to prevent the body from being drawn downwards. 

The machine of Bellocq, described and engraved in the 
third volume of the Memoirs of the Academy of Surgery, is 
at present generally abandoned. By it, extension is made in 
the direction of the limb, on the lower part of the leg, and 
gradually; but the counter-extension acts immediately on the 
superior part of the thigh: besides, the great difficulty of ap- 
plying this machine, justifies the oblivion into which it has 
fallen. Many other apparatus successively proposed after that 
of Bellocq, and of which they were but modifications, have, 
like their model, fallen into dis-use. 

The machine of Hook, perfected by Aitken, and described 
by Bell, acts in the direction of the limb, and produces a slow 
and gradual extension, by means of screws, but it has the dis- 
advantage of acting immediately on the inferior part of the 
16 



122 OF FRACTURES OF THE FEMUR. 

thigh, and on a small surface. Thus, while two precepts are 
observed, two others not less important are neglected: besides, 
nothing opposes the falling outward of the foot and knee, nor 
the inclination of the hip to the same side. 

Desault perceived all these imperfections and defects, and 
invented an apparatus by which the object proposed is more 
perfectly attained, and by means much simpler. It might be 
added perhaps, that with a few modifications, it would com- 
prise every advantage that can be expected from such an appa- 
ratus. His first attempts were directed only to correct the an- 
cient methods. He attached the trunk to the head-board of 
the bed, by means of long bands fastened to a bandage passed 
under the arm pits: he applied, in the next place, the middle 
of a band on some thick compresses placed on the back part 
of the leg, a little above the ankles; the extremities of this 
band crossed on the superior part of the foot, and knotted on 
the sole, were then fastened to the foot of the bed. To this 
disposition was joined the ordinary means or apparatus. This 
method had a disadvantage of which we have already taken 
notice, namely, the facility with which the bands relax; be- 
sides which, the immobility of the body was very fatiguing, 
and the difficulty of breathing, on account of the bandage 
round the trunk, was still more distressing. This last menti- 
oned disadvantage induced Desault, in a particular case,* to 
apply the bandage on the pelvis, to which it was fixed by 
bands passed under the thighs. 

Desault ascertained by different experiments, that the ob- 
ject particularly to be aimed at, and which was essential, was 
such a disposition as that the foot, leg, thigh, and pelvis, 
should constitute but one whole; so that, though the different 
parts thereof should be drawn in different directions, yet they 
should still, with respect to one another, preserve the same 
mutual relation. Convinced of the justness of this conclusion,, 
he invented the following apparatus to answer these purposes. 

A strong splint, long enough to extend from the ridge of 
the os ilium to a certain length beyond the sole of the foot, 
is a principal part of this apparatus: this splint should be two 
inches and a quarter broad, and have each of its extremities 
pierced in shape of a mortice, and terminated by a semicircu- 
lar niche. It is applied on the exterior side of the thigh, by 
means of two strong linen bands, each being more than a yard 
long. 

* Surgical Joyrnal, vol. i. 



OF FRACTURES OF THE FEMUR. I 2 J 

The middle part of* one of these bands is to be applied to 
the inside of the thigh, at its upper part; its ends are brought 
to the exterior side of the thigh, passed through the mortice, 
and knotted on the semicircular niche. Compresses are to be 
previously placed under the middle part of the band, in order 
to prevent any disagreeable pressure; as well as on the tubero- 
sity of the ischium, which Desault considered as the principal 
point of action of this band. The inferior part of the leg is, 
in the next place, covered with compresses, on which the mid- 
dle part of the second band is placed: the extremities of this 
band are crossed on the instep and upper part of the foot, then 
on the sole, after which they are conveyed outward, and one 
end passed through the mortice and knotted with the other on 
the niche, with such a degree of force as to pull the inferior 
portion of the femur downward, and to push the splint up- 
ward, and by this means the pelvis and superior fractured por- 
tion. On the internal side of the limb is placed a second 
splint, which extends from the superior part of the thigh, to 
a certain distance beyond the foot. A third is placed on the 
anterior part, and extends from the abdomen to the knee. 
The superior extremities of the anterior and exterior splints 
are fixed by means of a bandage passed round the pelvis. A 
band, the middle part of which is placed under the sole of 
the foot, and the extremities crossed on its superior surface 
and fastened to the splints, prevents the motion of the foot, 
as does also to a considerable degree the action of the splints. 

It may not be superfluous, perhaps, to remark, that previ- 
ous to the application of this apparatus, the whole limb should 
be covered with compresses, moistened with a solution of the 
acetate of lead, and that Seultet's bandage is to be applied on 
the thigh and leg over these compresses^, and a roller to be 
passed round the foot: these parts of the apparatus should be 
moistened with a resolvent liquid. These have the double ad- 
vantage of diminishing the irritability of the muscles, and pre- 
venting any stagnation of the fluids. 

This apparatus of Desault's has, in the hands of that cele- 
brated surgeon produced a great number of cures; but it must 
at the same time be acknowledged that it has frequently failed: 
the causes of failure may be found in defects which it is easy 
to point out. 

The superior band has a triple disadvantage; first, that of 
forcing the inferior portion of the femur outward; secondly, of 
pushing the superior upward; thirdly, of rolling itself into a 



124 0F FRACTURES OF THE FEMUR. 

cord, compressing thereby painfully the adductor and rectus in- 
ternus, the spasmodic contraction, of which, in consequence of 
the pressure, tends still further to produce the ascent of the 
inferior portion of the femur. These disadvantages would be 
all removed, by giving the band a point d'appui on the tuberosi- 
ty of the ischium. 

The difficulty, however, of acting on a globular eminence 
of a small surface, and covered by a great depth of soft parts, 
is easily seen: the extension of the thigh on the pelvis increases 
this difficulty, by increasing the depth of the soft parts. This 
tuberosity would be more prominent for the inverse reason, 
if, according to Pott's method, the limb were placed in the 
half-bent position. The difficulty of acting on this tuberosity 
is much greater in women than in men, on account of the 
greater quantity of cellular substance about this part in females. 
Not only is it difficult to make the band act on that tuberosity, 
but other disadvantages result from it; for the great pressure 
of the band on these delicate parts, causes much pain, ulcera- 
tion, and sometimes gangrene. To these circumstances De- 
sault attributed the ill success which he sometimes met with. 

The inferior band has nearly the same disadvantages as the 
superior; its direction is oblique downward and outward, and 
its action tends therefore to produce a derangement of the 
pieces of bones. This tendency is counteracted, it is true, by 
the band directed to be applied to the back part of the leg 
above the ankle, crossed on the superior and inferior surfaces 
of the foot, and fastened to the lower extremities of the in- 
ternal and external splints. The compresses with which the 
inferior part of the leg is covered, do not always protect it 
from the extreme constriction of the lower band, which being 
narrow, forms itself quickly into an hard cord, and causes 
pain by acting on a narrow surface. The gangrenous eschars, 
which are sometimes produced by the constriction of this band- 
age, are so considerable, as to denude in many cases the ten- 
do Achillis, and the tendons of the extensor muscles of the 
toes. These tendons, exposed to the contact of the air, are 
apt to exfoliate, and consequently the bones which they are 
destined to move will remain motionless. The oblique action 
of this band renders a great constriction necessary. 

If, in order to appreciate exactly the merit of this method, 
we compare its manner of acting with the general rules alrea- 
dy laid down for effecting perpetual extension, we shall find 
that some of these rules are transgressed, and others not com- 



OF FRACTURES OF THE FEMUR. 1 25 

®letely observed. Thus the extending force acts on that part 
of the limb which articulates with the inferior fractured por- 
tion; but the superior band acts on the superior fractured por- 
tion; and the bands being narrow and liable to roll up like a 
cord, do not aft on large surfaces. Both the inferior and su- 
perior bands being oblique, they cannot aft in the direction of 
the bone. Finally, their action cannot be gradually increased. 
The method of Citizen Boyer, which remains to be described, 
is strictly conformable to all these rules. By his apparatus and 
method, the extension is gradual and in the direction of the 
bone; and none of the muscles which surround the fractured 
bone are compressed. 

The apparatus consists of a splint, a sole, or slipper, and a 
sous-cuisse. The splint should be four feet long, three fingers 
breadth wide, and about four or five lines in thickness, and 
made of hard and inflexible wood. A groove about half an 
inch wide, the extremity of which is covered with iron, runs 
along this splint for about half its length. In this groove is 
placed a screw which occupies its whole length, one end of it 
being supported against the plate of iron with which the ex- 
tremity of the groove is covered, the other being adapted to a 
key by which it is turned. To this screw is fastened, in the 
manner shewn in the plate, an apparatus to which the sole is 
fixed. The superior part of the splint is received into a pocket 
formed in the sous-cuisse. The sole is made of iron, and co- 
vered with shammy leather; towards the heel a large piece of 
soft leather is attached to it, which piece is divided into two, 
and serves to fix the sole to the foot. It is fixed to the part 
of the apparatus connected with the screw. 

The sous-cuisse is composed of two parts, which meet at an 
acute angle. It is made of strong leather, covered with sham- 
my and well stuffed with wool, like the girdle of a truss; one 
of the parts should be long enough to pass obliquely round 
the upper part of the thigh, its extremity terminating in a 
strap pierced with holes: the other should be only three inch- 
es long, and terminated by a buckle. At the place where both 
parts meet, a piece of leather is sewed in form of a pocket, 
into which the superior part of the splint is received. 

It is difficult to give a satisfactory explanation of all the par- 
ticular parts of which this apparatus is composed; but a suffi- 
ciently correct idea of it may be formed by taking a view of 
the Dlate No. 2. 



126 OF FRACTURES OF THE FEMUR. 

The apparatus is applied in the following manner: after ha- 
ving surrounded the upper part of the thigh with a soft gir- 
dle of cotton three inches broad, the sous-cuisse is applied over 
it. Then the foot and lower part of the leg is surrounded 
with some soft matter, in order to secure against the effects of 
pressure, and the sole is applied to the foot. Next the superi- 
or part of the splint is introduced into the pocket of the sous- 
cuisse, and the sole is attached at the proper place to the re- 
mainder of the apparatus. 

The application being thus far advanced, the necessary stuff- 
ing and two splints, one anteriorly, the other internally, are 
applied and secured in the ordinary manner. Every thing be- 
ing thus disposed, the screw in the groove is turned by the 
key, and the sole descends and brings the foot with it, whilst 
the superior part of the splint is pushed upwards. In this 
way the limb may be extended gradually, and the extension 
increased as may be necessary. 

Which ever apparatus is adopted, it will be necessary to exa- 
mine it frequently, to tighten the bands, which are quickly 
relaxed in Desault's apparatus, and to give a few turns to the 
screw in that of Boyer; but for the latter, not near so much 
attention is necessary: the straps of skin by which the exten- 
sion and counter-extension are made, though over extended 
by any accidental cause, return again to the proper degree of 
constriction, on account of their elasticity; and though they 
should become relaxed, the means of bracing them are easy. 
When Desault's apparatus is used, it will be necessary to in- 
crease the thickness of the compresses on the back part of the 
leg, the tuberosity of the ischium, and inside of the thigh, as 
soon as these parts begin to excoriate. 

Topical applications, except those necessary for combating 
the inflammatory symptoms, are absolutely useless. If there 
be contusion and violent inflammation, the removal of these 
must precede the application of any apparatus. The bed on 
which the patient is laid, should not, as already mentioned, be 
too soft, but ought to be, on the contrary, firm enough to 
prevent his sinking into it. By adopting Desault's method, or 
that of Boyer, the patient may satisfy his natural wants with- 
out inconvenience. 

The general rule of confining the patient to a low regimen 
should be modified in the present case; because in this, more 
than in any other, it is necessary to support and increase the 
vital action of file parts. A rigourous abstinence, which would 



OF FRACTURES OF THE FEMUR. \T] 

in other cases only retard the formation of callus, might to- 
tally prevent it in this. Therefore, though the quantity 
of nourishment should be less than that used in a state of 
perfect health, because the exercise taken in that state ren- 
ders reparation more necessary, yet any abstinence that might 
induce debility should be avoided. 

Does the difficulty with which fractures of the neck of the 
femur consolidate, authorize the use of internal remedies, which 
might accelerate the consolidation? 

The ancients were of opinion that in a few days after a frac- 
ture the patient should be nourished with rich gelatinous food. 
Andre de la Croix,* and Fabricius ab Aquapendente, pre- 
scribe formally, in imitation of Galen,f the use of farinaceous 
and young animal food, and that of inspissating medicines. 
Ambrose Pare;j: has given the same directions, and observed 
them himself in the treatment of the fracture of his leg. Fa- 
bricius Hildanus§ remarks with reason, that aliments of this 
kind are difficult of digestion, and must therefore be very un- 
fit for a patient in a state of inactivity. But the same objection 
lies against the^ use of osteocolla, recommended by the same 
practitioner, and condemned by Van Swieten,H on the same 
principle as the inspissating or viscid aliments of Galen. Osteo- 
colla, so highly recommended by Fabricius, has been used by 
the greater number of surgeons. Some cases are found in the 
Philosophical Transactions,** in which the production of a part 
of the femur is attributed to the use of it ; but Citizen Pinel, 
translator of this work, judiciously remarks, that it is difficult to 
conceive how a stone of a calcareous nature, and of the melac- 
tite species, could aid the generation of callus. The use of 
gelatinous food which came into use on the supposition of its 
being of a nature analogous to the supposed osseous fluid, has 
been discontinued; and the theory on which it was founded, 
has been abandoned. Spirituous liquors, recommended to- 

* Dum substantia cartilaginea, compacla ac densa, quam Latini call urn 
vacant, gignilur; eo tempore viscosum alimentum commendatur. An- 
djeasa Cruce, vol. ii. lib. i, cap. 6, de Cibo. 

f De Methodo, lib. 6, cap. 5. 

\ Lib. 15, cap. 28. 

§ Surgical Observations, Cent. 1. Obs. 92. 

j| Comment, on Hermann Boerh. Aph. 

** Abiidgment ©f the Phil. Trans.— Med. and Surg, 



128 OF FRACTURES OF THE FEMUR. 

ward the end of the treatment, for the purpose of hardening 
the callus, have, in like manner, fallen into disuse. 

Nourishment easy to digest, and the moderate use of spirit- 
uous drinks, particularly for old people, aid that expansion of 
the vascular texture, necessarv for the generation of callus. A 
scrupulous attention should be paid to the manner of living, 
when the vital forces are found to languish from any cause 
whatever. 

The time which nature employs for the consolidation of a 
fracture of the neck of the femur,* has already been men- 
tioned. We repeat however, that the apparatus should not be 
finally removed before the sixteenth or seventeenth day; and 
that three months must elapse from the day of the fracture to 
that on which the patient may be safely allowed to quit his bed, 
and walk even with the aid of crutches. The premature use of 
the limb has been more than once the occasion of its being 
shortened, after the formation of the callus had been conside- 
rably advanced, and a cure without blemish on the point of 
being effected. A shortening of the limb is particularly to be 
apprehended, if the pieces are united by means, of a ligamento- 
cartilaginous substance. That the premature use of the limb 
may occasion this unfortunate accident may be easily conceived, 
by reflecting that the callus does not attain its ultimate degree 
of consistence until after the lapse of several months. 

A stiffness in the articulation is not much to be apprehended, 
though some instances of it are related by authors; these exam- 
ples would be more numerous, if the stiffness were produced by 
an effusion of osseous juice into the articulation, as some au- 
thors have thought. It is well known at present that this 
stiffness or false anchylosis is owing to the impeded circulation 
in the part, and to the muscles having lost the habit of motion 
by a long inactivity. Fractures of the patella and olecranon are 
more frequently than any others attended with this conse- 
quence. 

To this description of the treatment of fractures of the neck 
of the femur, we have only to add, that cases occur in which 
the approved method cannot be adopted. I have often seen 
patients who could not support the pain produced by it. In 
which case, or in that of the patient's being old, the continued 
extension ought not to be persisted in: the apparatus for frac- 

* The consolidation was always effected from the forty-fifth to the fif- 
tieth day, according to the cases related in the Surgical Journal,. 



OF FRACTURES OF THE PATELLA. I 29 

tares of the body of the bone must be had recourse to, with 
the additional precaution of guarding against the rotatory de- 
rangement, by making the internal and external splints extend 
beyond the foot. A cure thus obtained, will be attended with 
a shortening of the limb. 

If the patient were abandoned to nature, the continual mo- 
tion which would take place, and the friction^ would destroy 
the head of the bone, and often too what remains of the neck, 
as has been observed by Morgagni. The shortening is so great 
in that case, that the limb is nearly useless. Boehmer has ju- 
diciously remarked, in his Osteologic Institutions, that the de- 
ficiency alone of a point d'appui would cause lameness, though 
the member should have lost no part of its length. 



CHAPTER XV. 



OF FRACTURES OF THE PATELLA. 



THESE fractures may be transverse, or of different de- 
grees of obliquity, but are seldom found longitudinal. 
The transverse fracture is frequently occasioned by a sudden 
and violent contraction of the extensor muscles of the leg, 
which act on the patella: this cause remained a long time un- 
noticed, and the fractures produced by it were ascribed to the 
fall which was the consequence of the fracture. It is at pre- 
sent generally acknowledged to be the immediate cause of the 
fradture, and by that means the cause of the fall. 

It will be asked, perhaps, why the tendon of the extensors 
of the leg, and the inferior ligament of the patella, are not 
ruptured rather than the patella itself? To which it may be 
answered, that the extensibility of the tendinous and ligamen- 
tous parts renders them less liable to be ruptured than the pa- 
17 



IjO OF FRACTURES OF THE PATELLA. 

tella, the hardness of which is more than compensated by its' 
brittleness as an osseous substance. 

Though fracture of the patella is the most frequent conse- 
quence of a violent contraction of the extensors, yet a rupture 
of their tendon and the inferior ligament is sometimes pro- 
duced by the same cause. In both cases the symptoms, prog- 
nosis, and indications, are the same; and the treatment is per- 
fectly identical. 

To form a correct idea of the manner in which fractures of 
the patella take place, it is necessary to recollect, that the erect 
posture is the firmest possible, when the centre of gravity is in 
a line perpendicular to the basis on which the body is support- 
ed; that though the line passing through the centre of gravity 
may cease to be perpendicular, yet the body does not fall, but 
is kept erect by the action of muscles, which counteracts the 
deviation from the perpendicular direction: finally, that if this 
line fall on no part of the base, the body must necessarily fall 
towards that side to which the line inclines. 

If the centre of gravity fall behind the base, so that the 
body tends backwards, the extensor muscles of the leg contract 
with great violence, in order to prevent the flexion of the 
thighs, at the same time that the superior part of the body is 
also drawn forward by the contraction of muscles, and the cen- 
tre of gravity replaced on its natural support. If this contrac- 
tion of the muscles be not sufficient to bring the body forward, 
the obliquity of the axis of the centre of gravity still increa- 
sing, the action of the muscles will increase in consequence; so- 
that the patella pushed forward by the inferior extremity of 
the femur, drawn with great force by the tendon of the triceps 
and rectus anterior, and retained in the opposite direction by 
the Inferior ligament, is fractured transversely. 

The effort made to resist falling is not the only occasion on- 
which the patella is violently acted on by an instantaneous con- 
traction of the muscles inserted into it. It is exposed to the 
effects of a violent contraction of the muscles in leaping, which 
as performed by the human species, consists principally in the 
sudden extension of the lower extremities, which are always 
bent to the leap : for which reason a fracture of the patella of- 
ten occurs in dancers, and always takes place the instant of their 
quitting the ground. Another circumstance in which a trans- 
verse fracture of the patella may take place, is that in which 
the point of the foot is forcibly impelled forward; an instance 
of which is found in the case of a soldier, who made an at- 



OF FRACTURES OF THE PATELLA. 1JI 

ifeempt to kick his sergeant. In this case, the manner in which 
the fracture takes place is analogous to that of the olecranon, 
produced by the action of throwing a stone. Another case of 
this fracture is that of a man brought to La Charite, in the 
.month of Pluviose, 8th year. This person was a coachman; 
his horses took fright while he sat negligently on the box; on 
which occasion he extended suddenly the right leg, at the same 
moment that the point of the right foot slipped off the board 
on which it rested. He felt instantly a very acute pain in the 
knee, and heard very distinctly, at the same time, a loud crack $ 
and, on applying his hand to the part, he found the patella 
fractured transversely, and divided into two pieces, which were 
separated an inch one from the other. These instances remove 
every doubt on the possibility of this fracture being effected by 
muscular action alone \ and if any further evidence were neces- 
sary, it would be found in a case of a fracture of this nature, 
which took place by the violent contractions of the mucles of 
the thigh of a man in convulsions. 

Falling on the knees is a no less frequent cause of transverse 
fracture of the patella: in this case it takes place easily when 
this bone, made to project by the flexion of the leg, strikes 
against some very hard, resisting body. When the leg is bent, 
the patella is supported only by its extremities on the superior 
end of the tibia, and the articular part of the femur, so that its 
middle part is without any support, and corresponds with the 
interval between the two last-mentioned bones: this space is 
.occupied by the adipose cellular texture found behind the infe- 
rior ligament of the patella. In this situation of the parts, the 
patella is easily fractured, because the middle part of it, which 
is unsupported, is the thinnest, and because it is steadily fixed by 
the action of the tendon and ligament which are inserted into it. 
The direction of the fracture depends generally on the shape of 
the body against which the knee strikes. Should, for instance, 
its projecting part be transverse to the patella, the fracture will 
have the same direction ; if longitudinal the fracture will be 
longitudinal, &c. The same may be said of the violent impul- 
sion of a body against -the patella. In all cases this bone may 
be broken into several pieces, and the soft parts lacerated ; or 
the fracture maybe complicated with a rupture of the capsular 
ligament, and an effusion of blood into the articulation. 

Transverse fractures of the patella are always attended with 
a separation of the fractured portions. When the cause of 
■fracture has been just sufficient to produce the solution of con- 
tinuity of the bone, without disorganizing its fibrous covering, 



tjl OF FRACTURES OF THE PATELLA. 

the derangement is at first scarcely perceptible ; but this mem- 
brane stretches in a little time. The slightest motions of the 
leg are sufficient fcr elongating, or even totally rupturing this 
substance : in which case the separation becomes instantly 
considerable, and the articulation, from being no longer sup- 
ported, bends under the weight of the body. The following 
case is a remarkable instance of a fracture, in which the sepa- 
ration of the pieces, and the fall which is the inevitable conse- 
quence of it, did not immediately follow the solution of con- 
tinuity. The person while dancing, heard a dull noise in the 
right knee, and felt a slight pain in the same part. Some mi- 
nutes after in walking about the room, he heard another crack 
'in the same knee, and tell without the power of raising himself. 
On being brought to La Charlie the portions of the patella were 
found separated an inch and three fourths, which with the other 
signs, left no doubt on the existence of fracture. An uniting 
bandage, such as is generally made use of Tor simple incised 
wound?, was applied, and renewed as often as its relaxation 
rendered it necessary. On the thirtieth day of the treatment, 
the knee was gently moved, in order to prevent a false anchy- 
losis, and the motion was afterwards continued every day until 
the patient quitted the hospital. An interval of about one line 
in breadth separated the two pieces, which was entirely filled 
up by a ligamentous substance, of a very inextensible nature. 

Two causes concur to produce the separation of the frac- 
tured portions j one of which is, the contraction of the exten- 
sor muscles, which always takes place when their natural ten- 
dency to contract is not opposed, and by which the superior 
portion is drawn upward on the superior part of the thigh: the 
second cause is the flexion of the leg, the principal bone of 
which draws downward the inferior piece which is attached to 
it. The separation will be, then, great in proportion to the 
force of muscular contraction, the degree of flexion of the leg 
on the thigh, and the extension or laceration, more or less of the 
tendinous expansion which covers the anterior surface of the pa- 
tella, and which is attached to the- lateral parts of that bone, and 
adheres strongly at the same time, to the capsular ligament. 

Nothing can be easier than the diagnosis of fractures of the 
patella. If this bone be fractured transversely, by a forced ex- 
tension of the leg, the patient falls, and remains without the 
power of rising. The fall may instantly succeed the fracture, 
or there may.be some interval. The impossibility of rising ex- 
ists also when the fracture is effected bv a fall on the knee. If 



OF FRACTURES OF THE PATELLA. JJ3 

raised by the aid of others, the patient falls again if he attempts 
to advance; he can, however, move backward, by drawing the 
soles of his feet along on the ground, and by taking care not 
to bend the knee. 

A boy fell on the ice the 11th Nivose, year 8, and fractured 
transversely the patella of the right side: his efforts to rise were 
to no purpose; he was therefore obliged to make his way on his 
back to a neighbouring house, sixty paces distant. He was 
there put on his feet, and, by leaning on another person, was 
able to walk backward three hundred paces to the place of his 
destination, from which he was conveyed to La Charite. On 
the 12th a slight degree of swelling manifested itself about the 
articulation ; to reduce which, and to calm the pain which was 
very acute, emollient poultices were applied. The inflammatory 
symptoms entirely disappeared on the eighth day after the acci- 
dent, at which time the usual apparatus was applied. Toward 
the conclusion of the treatment, the articulation was exercised 
gradually every day: the patient quitted the hospital in the be- 
ginning of Ventose, having the portions of the patella united 
by a ligamentous substance, half an inch broad. The great 
strength of this ligamentous substance rendered the joint of the 
knee sufficiently strong, though it was a little stiff on the pa- 
tient's quitting the hospital. 

Besides the signs resulting from the cause and circumstances 
of a fracture of the patella, there are others still equally eas^ 
to be ascertained, and not less conclusive. A depression is 
found on the anterior part of the knee, instead of the promi- 
nence naturally formed by the patella at that part : the two 
fractured portions, which are more or less separated one from 
the other, may be made to approach by extending the leg on 
the thigh, and bending the thigh on the pelvis; and they may 
be moved laterally in opposite directions: a crepitation maybe 
very easily produced, on account of the slight covering of soft 
parts. A case may occur however, in which the separation of 
the fractured portions cannot be distinguished, as when there is 
a great inflammatory swelling about the knee; but this uncer- 
tainty is of no importance, because, even were the fracture 
ascertained, nothing could be done to bring the divided por- 
tions together, until the inflammation had abated. 

Is the consolidation of a fracture of the patella analogous 
to that of other bones? or is the process of nature different in 
this case from what it is in all others? Some authors have 
been of opinion that the fractured portions of this bone are 



IJ4 0F FRACTURES OF THE PATELLA. 

susceptible of an immediate reunion, by being" placed in con- 
tact; but the greater number question the possibility of such 
a reunion; and assert, on the contrary, that the pieces are al- 
ways united by means of a ligamentous substance, which is 
long, thin, and very extensible, when the fracture has not been 
well treated; but which is, on the contrary, short, thick, and 
unyielding, when the treatment has been well directed. 

Camper is the principal author of the latter theory, which 
he supports by a great number of cases. The Academy of 
Surgery adopted it on the evidence of similar facts; and it is 
now brought forward in a Treatise on Surgery,* lately publish- 
ed in the north : we do not hesitate to subscribe to it. 

Those who maintain that the consolidation of a fracture of 
the patella is analagous to that of fractures of other bones, ap- 
peal to experience, and cite numerous instances of an immedi- 
ate reunion, which they attribute to a more perfect mode of 
treatment. But as this pretended immediate reunion has not 
been attested by dissection of the part after death, it is possi- 
ble that a very close connexion, by means of a ligamentous 
substance, scarcely perceptible to the touch through the inte- 
guments, may have been taken for an immediate union. A 
postillion received a kick from a horse the 8th Messidor, year 
6, which fractured the patella of the left knee, near its infe- 
rior angle: the fibrous expansion prevented the separation of 
the pieces for some time. The inflammatory symptoms not 
being intense, yielded quickly to the usual antiphlogistic treat- 
ment: the uniting bandage was applied, and the knee gradu- 
ally moved as soon as the progress of the cure allowed it to be 
done with safety. The patient quitted the hospital on the 1 8th 
Thermidor, perfectly recovered: and so small was the interval 
between the two pieces, that, without a very attentive exami- 
nation, it might be supposed that there was none. But had 
they who supported the theory of the union by a ligamentous 
substance, contented themselves with opposing their adversa- 
ries by facts, the question could not have remained long unde- 
cided. They attempted to -explain the fact; and their adver- 
saries, by being able easily to overthrow their reasoning, 

* " Patella fra&a, baud uti alia corporis human! ossa, verp callo concres- 
eit, sed fragmenta, solum mediaute substantia rlrmiore, celluiosa, cartilagi- 
nosa, cumligamento mucoso concunente, conglutinantur, er firmiori cica- 
trisatione ligamentoiutn continentur, quod constans experientia, in vivis 
et caclavaribus, nos edocuit.' 1 — Calljsen, Principia Systeniatis Chir* 
Hod. §1288. 



OF FRACTURES OF THE PATELLA, I3J 

thought that they had thereby proved that the fact never oc- 
curred, as if a bad explanation could invalidate a well attested 
fart. 

We have already shewn that the explanation of the non- 
consolidation of fractures, founded on the want of a perioste- 
um and lubrifkation of the fractured surfaces by the synovia, 
is vague. 

Some authors, supposing that the patella was differently or- 
ganized from other bones, have endeavoured to explain, from 
this difference of structure, the peculiarities of the consolida- 
tion of its fractures. But it does not differ in its organization 
from the other small bones of the body, among which it is 
classed by the greater number of anatomists. Like them, it is 
composed principally of a spongy texture, covered by a very 
thin layer of compact substance. The fibres of the patella, 
when perfectly ossified, are visibly the continuation of those of 
the tendon, in the midst of which it is formed. This direction or 
continuation of fibres is easily demonstrated by the action of ni- 
tric acid on the patella, the calcareous part of which it dissolves. 
f .Th.e consolidation of fractured bones is effected by the same 
process as the cicatrization of wounds of soft parts; that is, by a 
turgescence and expansion of the vascular texture of the part: 
hence, the less dense, and the more specifically light any bone 
is, the greater is the number of vessels which pass through it, 
and the less is the proportion of its saline parts to its volume -, 
and further, the more intimate and multiplied are its points of 
contact with the neighbouring soft parts, so much the more ener- 
getic is its vital action, and the more rapid its consolidation 
when fractured. The fractured surfaces of the patella, on 
which a great number of vessels are distributed, are, for the 
foregoing reasons, much disposed to the inflammatory turges- 
cence, so necessary for the union of divided parts; and the 
consolidation would be very prompt if the granulations could 
be brought into immediate contact, and if mechanical causes 
did not counteract the consolidating process. 

According to Callisen, the adipose cellular texture placed 
behind the inferior ligament of the patella, presses itself be- 
tween the divided portions of that bone, and prevents their 
immediate reunion. When the leg is fully extended, the in- 
ferior ligament of the patella is also, in a state of tension, and 
the cartilaginous trochlea of the condyles of the femur leaves 
no vacuum behind the patella: in which disposition of the 
parts, says Callisen, this cellular substance is forced upward 



1^6 OF FRACTURES OF THE PATELLA. 

and forward, and thrust between the pieces of bone, so as to 
prevent their contact and immediate reunion: but in no case is 
this cellular substance placed between the patella and anterior 
part of the condyles of the femur; and even though it should 
be placed there, and should insinuate itself between the frac- 
tured portions, yet it could not prevent their immediate reuni- 
on, if it were possible to keep them in contact by a proper 
apparatus. 

The impossibility of doing so is the sole obstacle to the im- 
mediate reunion of the fractured portions; and the cause of 
this impossibility is found in the contractility of the extensor 
muscles, which cannot be directly opposed by any bandage. 
For were it attempted to press down the superior portion, and 
confine it in its place by a bandage, it is plain that this means 
could only act perpendicularly to the muscles which tend to 
draw it upward, and cannot therefore be completely effectual ^ 
there remains, consequently, a greater or less interval between 
the two portions of bone, the fibrous covering of which be- 
comes turgid and inflamed from the tension and irritation, and 
insinuates itself into the interval, so as to fill it up entirely. 
Such, in our opinion, is the cause and mode of formation of 
this ligamentous substance. 

The strength, thickness, and inextensibility of this sub- 
stance, is in an inverse proportion with its length. When 
long, it is thin, weak, and extensible, and transmits but im- 
perfectly the action of the extensor muscles to the leg. When 
short, on the contrary, it is thick, strong, and unyielding, and 
does not perceptibly diminish the action of the muscles, nor 
impede the motion of the articulation. 

The diminution of muscular action is not the sole disadvan- 
tage resulting from the length of this ligamentous substance; 
the strength of the knee, the flexion of which is naturally 
graduated by the patella, is also diminished by it; for the low- 
er extremity of the femur having no longer its natural support 
and resistance, the flexion is sudden and abrupt: hence per- 
sons so affected fall from the slightest cause. Galen* relates 
the case of a wrestler, whose patella ascended on the anterior 
part of the thigh, in consequence of the rupture of its inferior 
ligament. Every flexion of the knee put this person in the 
most imminent danger of falling. Descending a declivity was 
painful to him, and he was always obliged to use a stick oa 

* De Usu Partium, lib. iii. cap. 15. 



OF FRACTURES OF THE PATELLA. IJ7 

Such occasions. Ambrose Pare* informs us, that those who 
have had the patella fractured have much difficulty in ascend- 
ing a rising ground, but that they can walk with ease in 
an horizontal direction. Duverneyf mentions the case of 
a young man, whose patella was raised above the condyles 
of the femur, and fixed there, in consequence of the rupture 
of its inferior ligament. This person could not walk up stairs, 
but could readily come down. MorgagniJ mentions a great 
number of similar facts. I might add several others, all con- 
curring to prove, that, when the knee has lost the support of 
the patella, walking on rugged uneven ground is very difficult, 
and ascending a steep place almost impossible. 

From what has preceded, it appears that the great object to 
be attended to in the treatment of fractures of the patella, is 
the diminution of the interval between the pieces, in order 
that the ligamentous substance, which is necessarily generated, 
may be as short and strong as possible. Previous to the appli- 
cation of the apparatus, means are to be used to prevent the 
accession of inflammation 5 or, if it has taken place, every ef- 
fort is to be made to remove it. As inflammation does not in- 
stantly succeed the fracture, its approach may be sometimes en- 
tirely prevented. The most efficacious remedies in such case 
are fomentations with a solution of acetate of lead, and parti- 
cularly cold applications, such as pounded ice, or very cold 
water. These remedies are particularly applicable before the 
accession of the inflammatory symptoms. When the inflam- 
mation supervenes, the afflux of humours to the part, which 
the irritation tends to produce, is to be opposed, and the return 
of these humours into the circulation favoured. Do we not 
find, that in plunging into a bath at the freezing point, any 
part which has been exposed to the action of an irritating 
cause, as, for instance, the immediate action of fire, or any 
injury which excites inflammation, is rendered in some degree 
torpid, or has its sensibility diminished? Which diminution cf 
sensibility is a mark of a partial suspension of the vital proper- 
ty of the part, and is accompanied with a great diminution of 
the pain. The principle of irritability resides in the nerves, 
they being the sole organs of sensibility. By a momentary 
extinction of that property, or by a considerable diminution of 

* OEuvres d'Ambroise Pare, b. xv. cap. 22. 

-f- Treatise on the Diseases of the Bones, vol i. 

X De Sedibus & Causis Morborum, Epist. 56, No. 27. 

18 



IjS OF FRACTlTkES OF THE PATELLA. 

it, do we not act against the cause of the evil, rather that* 
against its effects? Whatever may be the value of this reason- 
ing, experience teaches us, that in the case in question, and in 
all similar cases, the immersion of the part in cold water is 
useful, and should be continued for several hours, the water 
being frequently renewed, in order to keep up the cold. If 
the surgeon has not arrived in time to have recourse to this 
means, or if the contusion be so violent as to render inflamma- 
tion inevitable, the general antiphlogistic treatment is to be 
pursued, and adapted to the age, strength, temperament, &e. 
of the patient. The pain is alleviated, and the tension dimi- 
nished, by extending the leg. Bell recommends the applica- 
tion of a great number of leeches to the part; but it appears to 
us that this cannot be done with safety in the greater number 
of cases; for the irritation produced by their bites, added ta 
that already existing, might bring on gangrene of the part, 
and the patient's death. In most cases, as when the fracture 
is a consequence of a fall on the knee, the inflammation is in- 
considerable, and disappears in a few days-, then compresses, 
wet with a solution of acetate of lead, may be placed on the 
part, and the apparatus may be applied over them. 

If the contusion be excessive, and blood be effused into the 
articulation through its lacerated capsule, as well as into the 
cellular texture, the inflammatory symptoms will be violent, 
then an antiphlogistic regimen and copious blood-letting must 
be had recourse to; and should a suppuration take place, not- 
withstanding our endeavours, incisions should be made, in or- 
der to give a free issue to the purulent matter. This treat- 
ment is sometimes successful, but at other times, notwithstand- 
ing every precaution, the patient is cut off. Such was the fate" 
of a mason, brought to La Charite, whose patella had been 
crushed rather than fractured by the fall of a large stone. If 
the contusion be not confined to the anterior part of the knee, 
The leg should not be fully extended, but placed rather half 
bent, that being the position in which all the soft parts are 
equally relaxed. This position produces, it is true, a separa- 
tion of the divided portions of bone; but the treatment must 
be in the first instance directed against the inflammatory symp- 
toms rather than against the fracture. If the inflammation be* 
not subdued before the twentieth or twenty-fifth day, it will 
be useless to apply the apparatus; because the ligamentous sub- 
stance is already formed, and has acquired a tolerable consist- 
ence: its length is much greater than it would be, were it pas- 



OF FRACTURES OF THE PATELLA. I39 

■able to apply the apparatus, and the strength* of the knee is 
considerably diminished. The patient is doomed to the disad- 
vantage already mentioned, of not being able to walk on an 
uneven surface but with great difficulty, nor to ascend a rising 
place without some artificial support. When the inflammato- 
ry symptoms are subdued in this case, all that remains -to be 
done is to guard against a false anchylosis, by gradually moving 
the leg from the moment that it can be done with safety, un- 
til the motion is free, and not attended with pain. 

The conduct to be pursued when- the inflammation has been 
overcome in time to admit of the application of the apparatus, 
or when it was originally trifling, has been already pointed out; 
we shall, however, recapitulate the particulars: the leg is to be 
extended on the thigh, and the thigh is to be bent on the pel- 
vis. The limb is to be supported in this position by means of 
pillows, or some such bodies, placed under it from the buttock 
to the heel, and means are to be used to keep the fractured 
portions in contact. 

Some authors have been of opinion that this position was 
alone sufficient, and that all apparatus for confining the pieces 
are useless. This is the opinion of Valentin and Citizen Saba- 
tier, who relates in the Memoirs of the Academy of Surgery, 
1783, several cases of fractures of the patella cured by this 
position alone. But it must be observed, with all due de- 
ference to the opinion of these practitioners, that as no mea- 
sure is taken to secure against the motion of the limb 
or the irritability of the muscles, which tend incessantly to 
draw the superior fractured portion upwards, there is every 
probability that the interval between the pieces of bone will be 
considerable. Besides the ligament which fills up this interval 
will be still further lengthened, and therefore 'weakened, by 
the incautious motions of the limb; or it may be broken be- 
fore it has acquired its full consistence. This will inevitably 
be the case if the patient, from any cause, bend the knee for- 
cibly: such an accident would necessarily retard the cure, or 
totally prevent it, if frequently repeated. 

The bandage in the form of the figure 8, and composed of 
a band rolled up from both ends, the two globes of which are 
made to cross one another alternately in the ham, and to em- 
brace both sides of the patella, causes a congestion of the foot 
and leg, by not compressing the whole limb. Besides, the ac- 
tion of this bandage is oblique, and much of it is spent in 
merely compressing the neighbouring soft parts, which it irri- 



140 OF FRACTURES OF THE PATELLA. 

tales, and sometimes excoriates; neither is this inconvenience 
remedied by the pasteboard trough, and compresses proposed 
by Louis as an addition to this bandage. The part of its action 
which is employed on the fractured parts is always insufficient 
to keep them in contact, if the constriction be not greater than 
the patient can bear for any length of time. If, in order to 
avoid this disadvantage, the bandage be not drawn sufficiently 
tight, its object will be entirely frustrated, and its application 
useless. These defects, occasioned this bandage to be re- 
jected, and led to the invention of another much less objec- 
tionable. 

A bandage, which, instead of occasioning an cedematous 
swelling of the limb, obviates it by making an equable pressure 
on all its parts,- which acts in direct opposition to the muscles, 
which tend to separate the portions of bone, and which, by 
acting on these muscles, diminishes their irritability and en- 
feebles their action, must concur powerfully with a good posi- 
tion to effect a favourable union of the divided portions of the 
patella. The uniting bandage used for transverse wounds pos- 
sesses all these advantages, when modified as we shall present- 
ly mention. The relaxed state into which the parts are put 
by the extension of the leg on the thigh, and the flexion of 
the thigh on the pelvis, favours its action. 

In applying this bandage, one assistant fixes the pelvis, 
while another raises and supports the whole inferior extremity. 
The surgeon takes a strip of linen longer than the whole limb, 
and broader than the patella, extends it on the inferior part of 
the leg, and fixes it by several turns of a roller; he then turns up 
the inferior extremity of the piece of linen, over which he again 
winds the roller, which he continues to apply as far as the articu- 
lation of the knee. He then commits the roller to an assistant, 
while he himself extends the skin over the patella, lest it should 
sink or be thrust in between the pieces of bone, which he brings 
into as close contact as possible, and includes them in two long; 
compresses passed obliquely round them, and crossed in the 
ham. In the next place he extends the longitudinal piece of 
linen first mentioned on the knee and thigh, as before on the 
leg, and again takes the roller, which he carries obliquely over 
the compresses, observing at the same time to let the folds 
cross one another in the ham. The application of this roller 
is continued upward on the thigh, and by its means the longi- 
tudinal piece of linen is fixed nearly as far up as the groin, 
from which its superior extremity is turned downward, having 



OF FRACTURES OF THE PATELLA." I4I 

been previously drawn upward with, much force. The roller 
is again carried downward over this double strip, and continu- 
ed over the knee and leg until it is entirely applied. Another 
roller is passed several times on the foot, and the whole com- 
pleted by applying a long splint on the back part of the limb 
from the buttock to the heel. This splint is kept applied by 
means of several turns of a bandage passed round it, and the 
pressure made by it may be prevented from being inconvenient 
by placing a long cushion of chaff between it and the limb. By 
this means the patient is prevented from bending his leg, which, 
without this precaution, he would probably do, and thus frus- 
trate all our efforts. The pain arising from the constriction 
and continued extension renders it impossible for the patient to 
keep the limb extended without the assistance of a splint. 

This apparatus preserves the pieces of bone exactly in their 
place in the commencement; but as the circumference of the 
limb quickly diminishes, the rollers become relaxed ; the mus- 
cles which were acted on perpendicularly, are no longer suffi- 
ciently compressed; they therefore draw upwards the superior 
portion. But this separation will be very inconsiderable, if the 
patient be frequently visited, and the rollers tightened as often 
as they are found loose. 

This chapter might be much extended, by drawing from the 
profound oblivion in which they are buried the numerous ap- 
paratus invented at different and distant times for the treatment 
of fractures of the patella. Some advantage might, however, 
be derived from the use of some of them, such as the pieces 
pf metal, leather, or pasteboard, with an opening in the mid- 
dle for the reception of the patella. Or for these apparatus 
might be substituted two pieces of metal, covered so as to em- 
brace the patella. The concave sides of these metallic pieces 
might be covered with hair, in order to diminish the pressure 
on the soft parts. This apparatus does not exclude the appli- 
cation of the splint and rollers, &c. 

These general principles of treatment being once established, 
nothing can be easier than to apply them to particular cases. 

We shall describe another apparatus, which appears to us 
very capable of keeping the leg extended, and the portions of 
bone in the greatest possible state of approximation. This 
consists of a trough, long enough to extend from the superior 
part of the thigh to the small of the leg, and wide enough to 
receive the thigh and leg. Small buttons are fixed to the edges 
pf this trough, to which may be attached two straps, that cross 



142 OF FRACTURES OF THE PATELLA. 

one another, and are fastened in the following manner. The 
trough being lined with carded cotton or soft linen rags, the 
limb is placed in it in such a manner as that the calf of the leg 
shall correspond to its middle part: it is then fixed in that situ- 
ation by means of a circular bandage. One of the leather 
straps is then fixed to one of the inferior buttons, which rises 
vertically from the external edge or border of the trough, and 
conveyed upward and inward, and fastened to one of the supe- 
rior buttons of the internal side. The other strap is fixed in 
the same way from the inside outward, so that they cross one 
another at their middle part, and embrace the superior frac- 
tured portion in their inferior angle. It will be necessary to 
extend the skin over the patella before the straps are tightened. 
Compresses soaked in a resolvent liquid are then applied, and 
a few turns of the remaining part of the roller are passed round 
the whole. The extremities of the straps should be made of 
leather, but the middle parts of buffalo-skin stuffed with hair 
like a bandage for a hernia, in order to guard against any ex- 
coriation of the parts on which they press. The simple me- 
chanism of this apparatus may be more perfectly comprehended 
by means of the engraving, Plate 3, fig. 1 and 2. 

Some authors have been of opinion that the separation of 
the fractured portions, so far from injuring the motions of the 
knee, was, on the contrary, favourable to these motions ; and 
have in consequence, proscribed every species of bandage which 
could prevent that separation. These authors content them- 
selves with simply moving the limb after the disappearance of 
the inflammatory symptoms, in order to guard against a false 
anchylosis. They allow the limb to remain in the half-bent posi- 
tion. But a stiffness in the articulation of the knee is a conse- 
quence much less to be dreaded than the weakness and disabi- 
lity which necessarily result from the length of the intermedi- 
ate ligamentous substance : for -which reason this method has 
but very few partisans. It is applicable only in cases of a longi- 
tudinal fracture of the patella, which very seldom happens, 
and in which the pieces remain naturally in contact. An anchy- 
losis may be always guarded against with certainty, by begin- 
ning to move the articulation about the twenty-fifth day. If the 
treatment has been judicious and regular, no danger can re- 
sult from gentle motion of the joint at that period; and the 
extent to which the motion is carried may be increased every 
day until flexion and extension can be performed freely and 
without pain. 



f% 



hw 



m 




U3 



CHAPTER XVI. 



OF FRACTURES OF THE BONES OF THE LEG, 



SECTION I. 



Of FraBures of the Leg. 



JTT^HIS name is given to fractures of the leg when both the 
bones composing it are broken; and such fractures are 
much more frequent than those of the tibia or fibula singly. 
The middle part of these bones is that which is generally frac- 
tured; for the great thickness and strength of the superior part 
of the tibia render fractures at that part very rare; but the in- 
ferior, not being equally strong, is sometimes fractured, and 
with it the fibula. Both bones are generally fractured at the 
same height : this is a necessary consequence of the simultane- 
ous action of the fracturing cause. 

These fractures may be transverse or oblique, and are subject 
to every species of derangement. The longitudinal derange- 
ment is, however, much less common than the horizontal or 
angular. In the former case, the inferior pieces are almost al- 
ways drawn outward and backward, whilst the superior project 
internally and forward. The angular derangement may be pro- 
duced either by the action of the posterior muscles of the leg or 
the weight of the body, and in either case the angle will be 
salient anteriorly. The salient angle may take place posteriorly, 
if the heel be too much raised. The derangement in the cir- 
cumference arises from the inclination of the foot inward or 
outward, but it most commonly falls in the latter direction. 
The longitudinal derangement is extremely rare, and cannot 



144 OF FRACTURES OF THE LEG. 

easily take place in transverse fractures, on account of the con- 
siderable extent of the fractured surfaces; but in oblique frac^ 
tures the inferior pieces are almost always drawn upward by the 
action of the posterior muscles of the leg, in which position of 
the parts the lower ends of the superior portions project anteri- 
orly, and may be felt by the hand. Sometimes, however, 
when the solution of continuity is obliquely downward and out- 
ward, the anterior projection will be produced by the lower 
pieces. In some cases the pointed ends of the bones tear and 
penetrate the integuments in both kinds of derangement. 

Fracture of the leg is accompanied by all the signs or symp- 
toms mentioned in treating of fractures in general in the first 
chapter. Change of direction and shape of the limb, pain, and 
incapability of motion, mobility of the fractured pieces, and 
crepitation always distinct, &c. — all these circumtances render 
this fracture so evident, that it is impossible to be mistaken re- 
specting its existence. 

The prognosis, less unfavourable than in fractures of the 
thigh, varies according to the part of the bone fractured, the 
direction of the fracture, and many other circumstances. The 
fractures which take place near the knee are not much subject 
to derangement, on account of the thickness of the bone in 
that part ; but are however, more dangerous than those of the 
middle part, as being subject to be followed by a stiffness of the 
knee joint. Fractures of the inferior part are still more dan- 
gerous. Oblique fractures are very difficult to be managed; 
and when their derangement is upward and outward, the in- 
teguments are very apt to be torn by the projecting points of 
the superior portions of bone. 

As to the treatment of a simple fracture of the leg, the pa- 
tient is to be carefully undressed in the first place, and then 
laid on a hard and narrow bed, perfectly horizontal, and with- 
out any board at the end. Afterwards the apparatus are ar- 
ranged in the following manner: 1, three pieces of tape, or 
linen; 2, a square piece of linen cloth longer than broad; 3, a 
sufficient number of short pieces of linen to cover the whole 
leg, or Scultet's bandage; 4, two quadrilateral compresses; 5, 
three cushions of oaten chaff, and three splints, two lateral, 
long enough to extend from the knee to a small distance be- 
yond the sole of the foot, and a third anterior shorter than the 
leg. All the pieces of the apparatus being thus disposed, and 
the compresses and short bandages being wet with a resolvent 
liquid, an assistant takes hold of the knee with both his hands, 



OF FRACTURES OF THE LEG. I45 

mid another seizes the foot, having both his thumbs applied to 
its sole: while both pull in opposite directions, the surgeon per- 
forms coaptation. The moment that the bones come into their 
right situation is easily known, on account of the thin covering 
of the tibia anteriorly. The square compresses are then laid 
over the leg, and on them Scultet's bandage, commencing al- 
ways with the lowest pieces. The lateral splints, in the next 
place, rolled up in the square linen cloth, are applied in such 
a manner as that they may rest perpendicularly on their edges, 
nearly in contact with the leg, between which and them a bag 
of chaff is placed on each side, by means of which the depres- 
sions of the leg are filled up. The remaining chaff-bag is placed 
on the anterior part of the leg for a similar purpose, and over 
it the third splint. An assistant holds fast with both his hands 
the different pieces thus placed, while the surgeon secures them 
more permanently by means of the three linen bands, which he 
knots over the external splint, commencing always with the 
middle one. The apparatus is completed by securing the foot 
by means of a small band to the lateral splints, in order to pre- 
vent it from falling to either side. But as the foot might be 
forced to either side by the weight of the bed-clothes, this in- 
convenience is guarded against by means of a hoop placed per- 
pendicularly on its ends over the leg. If the patient's stomach 
be not full he should be bled, and afterwards confined to a low 
regimen. 

Not only is it useless to place compresses under the heel, as 
was practised by the ancients, but it is attended with manifest 
disadvantages. The heel being raised by these compresses, 
supports the whole weight of the limb; and the pressure some- 
times occasions gangrene, to such a degree, that the os calcis 
is laid bare. Besides, by the elevation of the heel, the frac- 
tured part of the leg loses its support, and a salient angle is 
produced backward by the weight of the limb. 

A roller cannot be substituted for Scultet's bandage, but in 
cases of children under two years of age. 

If on the day after the application of the apparatus, the foot 
be neither painful nor swelled, and a slight degree of oedema 
be alone perceptible in that part, the apparatus need not be 
removed. It will be necessary to tighten the external bands 
every day, and to wet the whole with a repellent liquid; and 
at the end of eight days the apparatus should be re-applied. 
Some practitioners do not change the first dressing for eighteen 
<*r twenty davs: but it frequently happens, that during this 
3,9 



I46 OF FRACTURES OF THE LEG. 

time the fractured portions become deranged in the direction of 
the diameter or axis of the bone, and that their consolidation 
has already advanced considerably in this vicious position. This 
derangement may be occasioned by some accidental or involun- 
tary motions ; some defect in the first application of the appara- 
tus, or (what is of the greatest importance) by the bed not be- 
ing perfectly horizontal. The practice of deferring for such a 
length of time the re-application of the apparatus, has probably 
originated from the use of the circular bandage or roller. The 
motion which should necessarily be given to the limb in re-ap- 
plying that bandage, was certainly a sufficient justification of 
the practice. In adopting the improved method which we have 
described, the whole apparatus should be re-applied ev ery seven 
days, and the external bands tightened whenever the relaxation 
may render it necessary. 

On the fortieth or forty-fifth day, the progress of consolida- 
tion may be examined; and if the callus be found solid, the 
circular bandage or roller may be safely substituted for that 
whieh we have described, and the patient may be allowed to 
sit up and take any convenient posture, and in a very short 
time to walk about with the aid of crutches. The stiffness of 
the knee and instep arising from the long inactivity, will render 
walking difficult for some time. 

For the three or four first days the patient should be allowed 
only broths, which may be gradually changed for more sub- 
stantial food. If he be costive during his confinement, clysters 
may be administered; and should other incidental symptoms- 
occur, they are to be combated by appropriate remedies. 

We shall not trouble our readers by treating particularly of 
compound fracture of the leg, because we could only repeat 
what we have already very minutely detailed. 

When the leg is fractured very obliquely, continued exten- 
sion ought to be employed, particularly when the points of the 
fractured portions penetrate though the integuments. In cases 
of this nature, in which there is some hope of preserving the 
limb, if the patient be strong and healthy, some blood should 
be taken from the arm, and the extending apparatus applied. 



m FRACTURES AF THE LEG, 1 47 



SECTION «. 



0/" FraElures of the Tibia. 

This bone bears the whole weight of the body transmitted to 
it from the femur, and is fractured on that account more fre- 
quently than the fibula, though it is much thicker and stronger 
£han the latter. But as fractures of it are almost always trans- 
verse, they are not very dangerous. 

If the fracture take place near the inferior extremity, the 
great extent of the fractured surfaces prevents any considerable 
derangement of the fractured portions; and the fibula acting as 
•a support on the external sides, contributes also to this effect. 
Besides there is no tendency to derangement from muscular 
action. 

This circumstance renders a diagnosis of fractures of the tibia 
often very difficult, and the difficulty is further increased by 
the little pain and inconvenience produced by such a fracture; 
for persons have been known to walk, although the tibia was 
at the same time fractured. 

Whenever there is reason to suspect this affection, in conse- 
quence of a blow or a fall on the leg, the part should be minute- 
ly examined. The fingers are to be moved along the anterior 
side of the tibia, the slightest inequality in which may be ea- 
sily perceived, on account of its being covered only by the 
skin; and the motion of the pieces may be perceived, by sei- 
zing the opposite ends of the bone and pushing them in contra- 
ry directions. This motion, however, and the crepitation 
which should accompany it, are very indistinct, on account of 
the fibula not allowing the fractured portions to be sufficiently 
moved on one another. 

The patient conplains of a constant pain in his leg, and par- 
ticularly near the seat of the fracture. This pain continues for 
a much longer time than that which is the effect of a mere 
contusion, and it is increased by walking. 

By means of these signs, the existence of this fracture may 
be ascertained; but little is to be done in the treatment of it. 
The slight derangement which has taken place, is to be correct- 
ed by moving the pieces in the direction opposite to that in 
which the derangement has taken place; but before giving 



14-8 OF FRACTURES OF THE LEG. 

them this motion, they should be drawn in opposite directions, 
in order to diminish the friction of the fractured surfaces. A 
long compress is then placed on the anterior part of the leg, 
and over that a roller or circular bandage-, with which the leg 
being covered, three splints of pasteboard, or thin wood, are 
applied and bound on by the part of the roller which remained 
unapplied. 

The patient is to be confined to his bed, and not allowed to 
use the affected limb until the fracture is consolidated. In 
cases of aged or adult persons, it would perhaps be more pru- 
dent to use the ordinary apparatus for fractures of the leg, than 
the roller. Whichever mode is adopted, the bandage may be 
taken off on the fortieth or forty-fifth day, at which time the 
consolidation is complete. The articulations of the knee and 
foot are but little affected by this fracture, and the slight stiff- 
ness of them, arising from inactivity, is soon removed, and the 
patient is able to walk about in a few days. 



SECTION III. 



Of Fractures of the Fibula. 

The fibula, though slenderer than the tibia, is less frequent- 
ly fractured. It is not charged with the weight of the body, 
and its principal use seems to be that of preventing the disloca- 
tion of the foot outwards, in a forced abduction. Thus we see 
that it is placed externally, descends below the articulation of 
the tibia with the foot, and forms the external ankle. It is be- 
sides more flexible than the tibia, and can execute in its double 
articulation with this latter bone some obscure motions, which 
consume a greater or less share of any force that might tend to 
fracture it. 

Yet, from the very nature of its functions, the fibula is ex- 
posed to certain fractures, of which no author has taken par- 
ticular notice. In every step that is made on an uneven ground, 
the foot presses against the inferior extremity of this bone. By 
this action of the foot on the external ankle, the fibula is pres- 
sed upward, and as the nature of its articulation with the tibia 
does not allow it to ascend in any perceptible degree, it is for- 
ced to bend more or less in proportion to the force applied. 



OF FRACTURES OF THE LEG, 1 49 

The elasticity of this bone enables it for some time to resume its 
natural direction, when the force is removed. But as the same 
force acts frequently, and is never intermitted but for very short 
intervals, the bone acquires insensibly a permanent bend, in- 
stead of being perfectly straight, as it is in the infant. This bend 
becomes more evident in proportion as age advances, and as the 
limb has been used. 

Climbing animals, such as the squirrel, and others, whose 
feet are always in a forced abduction, have the fibula stronger 
in proportion, and more convex externally, than it is in the 
human species. It has been observed by Citizen Cuvier and 
Dumeril, that in the animal called the three-toed sloth, the 
inferior extremity of the fibula is inserted into a socket on the 
superior surface of the astragalus, in such a manner as that the 
foot must be considerably strengthened by it, and secured 
against dislocation by the extreme abduction which this animal 
ii obliged to make, in grasping the trunks of the trees on 
which he climbs. 

The motions of adduction and abduction, in which the 
sole of the foot is turned inwards or outwards, are very limit- 
ed in the human species, and much less extensive than those 
of flexion and extension. It sometimes happens, however, 
that the foot, from missing its support, or being entangled by 
something, is turned forcibly inwards or outwards; in which 
case the ligaments of the articulation are always strained, and 
very frequently lacerated. It is in a case of this kind, when 
the foot is forcibly turned outwards, that the fibula is fractured 
by the pressure of the astragalus, the dislocation of which, out- 
wards, it prevents, when the foot is forcibly turned in the same 
direction. 

The action of the foot is always the immediate cause pf 
fracture produced in this way. If the convexity of the fibula 
outwards were uniform, so that the whole length of the bone 
should form an arch of a circle; if it were of an equal thick- 
ness and strength in all its parts, and if its muscular and liga- 
mentous connexions with the tibia were also of an equal 
strength in every part, the fracture would always take place in 
its centre: but none of these conditions exist, and the fracture 
takes place generally below its middle half. If the abduction 
of the foot has been very violent and sudden, the fibula may 
be fractured at about an inch above] its lower extremity, by 
which the external ankle is separated from the body of the 
bone. 



I50 OF FRACTURES OF THE LEG. 

To the fractures produced by this cause are to be added 
those resulting from a fall, or a blow on the external side of 
the J eg, in which the bone always yields in the part to which 
the force is immediately applied, and in a direction opposite to 
its natural curve. 

Whatever be the manner in which a fracture of the fibula 
is produced, the pieces are not susceptible of the longitudinal 
derangement*, but are in all cases drawn a little towards the ti- 
bia, by the muscles placed in the interval between them. 
Hence a fracture of this bone will be best ascertained by press- 
ing the fractured portions inward, as it is in that direction that 
their motion can be best perceived. This symptom, and cre- 
pitation, which is a consequence of it, may be also observed 
in the abduction and adduction of the foot. These signs are 
more evident when the fracture takes place near the inferior 
extremity, than when it happens near the superior, which is, 
covered with thick muscles. But a fracture of the lower part 
may be very difficult to be ascertained, when the articulation 
of the foot has been at the same time violently strained, and 
the inflammation and swelling have arrived at a great height. 
In cases of this nature, some practitioners turn all their atten- 
tion to the affection of the articulation, that is to reduce the 
luxation of the astragalus, and combat the inflammatory symp- 
toms, without doing any thing for the fracture. 

But so imperfect a mode of treatment must be attended with 
the worst consequences. The peronei muscles, which extend 
the foot by raising its external edge, and turning its sole out- 
ward, act incessantly, and draw the fcot gradually into that 
position. The fractured portions are deranged longitudinally, 
the inferior being drawn upward along the internal side of the 
superior. The astragalus is carried under the internal ankle, 
and forms a considerable tense tumour there; the skin becomes 
inflamed and ulcerated at this part, and a fistula is formed, 
which communicates with the articulation of the foot. The 
patient cannot support himself on the affected limb, and in 
time the symptoms become more and more alarming, and may 
lead to the necessity of amputating the part. Fabre quotes two 
examples of the bad consequences resulting from neglecting 
a fracture of the fibula*, they are to be found in his Researches 
on certain Points of Physiology and Pathology. I have my- 
self seen the foot distorted, and the fracture not consolidated, 
in the case of an old man, who died of a malignant fever, i^i 
one of the medical wards of La Ckarite. 



OF FRACTURES OF THE LEG, 1 5 I 

It will therefore be prudent, in every case of a strained foot, 
to examine carefully the lower extremity of the fibula, and to 
apply an appropriate apparatus, if there be the slightest sus- 
picion of a fracture. The first step of the treatment should be 
to cover the affected part with emollient poultices, and to take 
some blood from the arm ; and if it be found that the bone is 
fractured, so soon as the swelling and inflammation are abated, 
Scultet's bandage should be applied, and the distortion of the 
foot prevented by means of two splints, which descend from 
above the knee, to a short distance beyond the foot externally, 
and internally as low as the ankle. It is perhaps superfluous to 
repeat that the splints should be rolled in a splint-cloth, and 
tied on with bands, and that bags of chaff should be placed 
between them and the leg, in the depressed parts. 

This apparatus should be continued for a month, and fre- 
quently removed, in order to renew the emollient applications. 
In this lapse of time, the fracture generally consolidates, but a 
stiffness remains in the joint, of which it will be prudent to 
warn the patient. This, however, will be removed in a few 
months by bathing and friction, but above all by exercise, the 
suspension of which was its principal cause. 

If the fracture take place towards the middle part of the 
bone, the ordinary apparatus for fracture of the leg should 
be applied, and thick compresses placed on the anterior and 
posterior sides of the leg, by means of which the anteropos- 
terior diameter being increased, the bandage can act in that di- 
rection, and press the fleshy parts into the interosseous inter- 
val, and thus prevent the fractured portions from obeying their 
tendency to approach the tibia. But preserving the interos- 
seous interval is not so important here as in the fore-arm, be- 
cause in the former it merely serves to lodge some muscles; 
the foot not having to execute any motions which require the 
rotation of the fibula on the tibia. 



H 



CHAPTER XVII. 



OF FRACTURES OF THE BONES OF THE FOOT. 



SECTION 1. 



Of the FraBures of the Os Calcis. 



THE solidity of this bone, the three dimensions of which 
are nearly equal, renders it but little liable to be fractu- 
red. The causes by which it may be fractured are muscular ac- 
tion and external violence, and in this respect it resembles the 
olecranon and patella. The violent and instantaneous contrac- 
tion of the gastrocnemii muscles is sufficient to detach from the 
remainder of the bone that part of it called the tuberosity, into 
which the tendo Achillis is inserted, and which extends back* 
ward beyond the astragalus. Though the gastrocnemii muscles 
are at least as strong as the- extensors of the arm or leg, yet 
fractures of the os calcis are, on account of its thickness, much 
less frequent than those of the patella or olecranon. Fractures 
of it are also less frequent than the rupture of the tendo Achil- 
lis, the contrary to which takes place with respect to the ten- 
dons of the extensors of the arm and leg, which are stronger 
than the osseous parts to which they are attached. 

Some rare examples of fracture of the os calcis from muscu- 
lar action may be cited : that, for instance, of a woman detain- 
ed against her will at La Salpetriere. She converted her sheets 
into a rope, and by means of them descended from her win- 
dow; but the sheets not reaching to the ground, she let her- 
self drop on her feet. On touching the ground, she heard a 
erack in one of her heels, and fell without the power of rai- 



OF FRACTURES OF THE OS CALCIS. I J3 

sing herself. On examination the os ealcis was found to be 
fractured. 

The existence of this fracture is discovered by the circum- 
stances of the case: a fall on the sole of the foot; a crack 
heard in the moment of the fall; pain, which is increased by 
the motion of the part; the almost absolute impossibility of 
standing or walking; a greater or less swelling of the heel; 
the mobility and elevation of that part of the os ealcis into 
which the tendo Achiilis is inserted; finally, the crepitation 
and interval between the fractured portions — are all marks 
which separately or conjointly lead to the discovery of the 
fracture, it may be observed, however, that the separation of 
the fractured portions is not easily ascertained, on account of 
the thickness of the integuments. 

In setting this fracture, it is necessary to extend the foot on 
the leg, and to bend the leg on the thigh. In this position the 
two portions of the os ealcis can be very easily brought into 
contact, the superior of which is drawn upward by the gastroc- 
nemii muscles. 

The foot and leg are kept in this position all the time neces- 
sary for the consolidation, by means of the slipper invented by 
J. L. Petit for a rupture of the tendo Achiilis. 

The uniting bandage used for transverse wounds may be 
substituted for the slipper, when from local circumstances, the 
latter cannot be had; but it must be modified as follows: the 
end of a bandage is placed on the superior surface of the foot, 
whence the bandage is reverted on the sole, and the end is 
made fast by circular casts round the foot: this bandage is then 
drawn along the posterior side v of the leg to the ham (the foot 
being previously extended), on which part it is fixed by other 
circular casts: it is thence brought downward forcibly, and the 
application of it terminated by rolling along the leg what re- 
mains. To this bandage might be added a long compress, the 
middle part of which should be applied above the posterior 
portion of the os ealcis, and the extremities crossed on the su- 
perior surface of the foot, and turned under the sole. This 
compress may be fixed by a bandage rolled on the foot in the 
shape of the figure 8. 

The union of this fracture is effected in thirty or forty days, 
at the end of which time the patient may be allowed to bend 
his foot. He must, however for some days, avoid any forced 
flexion of the foot, as also an excessive extension by rising on 
his toes. 

20 



154 OF WOUNDS, AN© 

The other bones- of the tarsus, as the astragalus, cuboides, 
scaphoides, and the three ossa cuneiformia, are susceptible on- 
ly of comminutive fracture. The same may be said of the 
bones of the metatarsus, and the phalanges of the toes. On 
the treatment of fractures of these bones we have nothing to 
add to what has been already said in general on compound 
fractures, or in particular on fractures of the bones of the hand. 



CHAPTER XVIII, 



OF WOUNDS, AND DENUDATION OF BONES. 

THE bones may be stripped, not only of the integuments,; 
muscles, &c. by which they are naturally covered, bun 
also of the periosteum, which is their intimate and appropri- 
ate covering. 

Gutting or contunding Instruments may produce this denu- 
dation of the bone without injuring its substance, or they may 
cut or contuse its external fibres. These two cases must be 
carefully distinguished, as the contusion of the bone is attend- 
ed with consequences much more serious than those of a simple 
denudation. 

If the bone has been' merely stripped of its periosteum and 
integuments, and these parts are immediately replaced, so as- 
to exclude the contact of the air and bandages, the reunion of 
the periosteum is found to take place in a very short time. 
But if the external laminae of the bone have been contused, or 
if its surface has been left a long time exposed to the action of 
the air, or to the friction of bandages, exfoliation becomes a 
necessary consequence. All the external laminae must separate;- 
and before this separation is effected, the cicatrization of the 
external wound would be rather injurious. Should the wound in 
the integuments be prematurely closed, purulent matter will 
continue to form underneath, the contused laminae will exfo- 
Mate, an abscess will point externally and burst spontaneously^ 



'DENUDATION OF BONES. 155 

and the matter that escapes from them will contain small splint- 
ers of bone. Old age is unfavourable to the healing of 
wounds and contusion of the bones; because, as the cure can 
be effected only by means of the vascular texture of the bone 
and periosteum, the turgescence and expansion of this must 
be slow and difficult in proportion to the person's age. The 
treatment adapted to the different cases is as follows: 

If the bone be simply laid bare, the integuments, if not 
completely separated, should be instantly replaced. This pre- 
cept holds good in all cases, whatever may be the patient's age, 
if the bone has not been already a long time exposed to the 
contact, of the air. At the same time it must be allowed that 
it is very difficult to know by mere inspection whether the 
bone be contused or not; but should that be the case, and^ven 
should suppuration and exfoliation be inevitable, no bad con- 
sequence can result from the attempt to produce an immediate 
cicatrization; whereas, in the contrary event, the duration of 
the treatment will be much abridged. If it be impossible to 
unite the wound by the first intention, its lips are to be kept 
separate by lint interposed, and the whole is to be lightly co- 
vered. In a short time granulations appear, and the external 
laminae of the bone' exfoliate. Sometimes, however, and par- 
ticularly in young persons, the bone becomes soft and red-, and 
granulations arise from it, which bleed from the slightest cause. 
It has been said, that the bone exfoliates insensibly in this 
case; but this observation is not found to be true: the laminae 
of the bone are not broken down, dissolved, and carried off 
by suppuration. The change consists of a softening of the 
bone, and conversion of it into a fleshy substance^ which unites 
with the soft parts. 

In this last mentioned case the cure is much, more prompt 
than when a real exfoliation takes place. The process of ex- 
foliation resembles that of the separation of gangrenous es- 
chars: the mode in which the separation is efiected is equally 
unknown in both cases. In exfoliation, it is merely known 
that the subjacent vessels grow turgid, expand, and pullulate, 
and that a line of separation is observed between the contused 
laminae and the sound part of the bone. The former are un- 
dermined, as it were, and their connexion shaken by the pu- 
rulent matter formed under them, and at length are entirely 
detached, and may be easily removed by the fingers or a for- 
ceps. When the bottom of the wound is entirely freed, the 



1^6 OF WOUNDS, &C. OF BONES. 

granulations that arise from it unite with the soft parts, and in 
a short time the wound is cicatrized. 

Various processes have been employed for expediting the 
exfoliation. Thus the ancients covered the bone with pledgits 
of lint impregnated with spirits, or with a tincture of myrrh 
and aloes; but it is found that these applications retard the ex- 
foliation by opposing the expansion of the vessels ; for which 
reason they have been laid aside, and oily relaxing applications 
have been substituted for them. 

It has been proposed to perforate in different parts the lami- 
na? which are to exfoliate, on the supposition that this practice 
facilitates the growth of the granulations. The perforations 
have certainly this effect, but the granulations, by shooting up 
through them, retain the lamina? rather than aid their exfolia- 
tion: each vessel spreading as it rises, and assuming in some 
respect the shape of a broad-headed nail. It will then be more 
prudent to limit the treatment to the use of unctuous or emol- 
lient applications. By means of these remedies, the texture of 
the part will be sufficiently relaxed, and the developement of 
the vessels facilitated. But if the portion of bone to be exfo- 
liated be very considerable and deep seated, these applications 
are nearly useless, at least their effect must be very trifling; 
then we must content ourselves with covering the part with 
lint, and trusting to time and nature for effecting the separa- 
tion. 

Though the exfoliation be complete, as may be known by 
the motion of the piece, it may still happen that the circumfe- 
rence of the detached portion may be encroached on by the 
growth of the soft parts, and thus prevented from separating. 
In this case it will be necessary to disengage it by making an 
incision in some point of the circumference of the wound, af- 
ter which it may be drawn out by the fingers or a forceps. In 
general, there is but very little difficulty in removing it. 

The action of cutting instruments is not always limited to the 
mere denudation of the bone \ they sometimes completely divide 
it: this, however, is but a rare occurrence. It sometimes hap- 
pens that a part of the bone is cut off, of which there are nu- 
merous instances in wounds of the head, where a part of the 
pariotal bone, with its pericranium, a portion of the occipito- 
frontalis muscle and hairy scalp, have been entirely separated 
by a blow of a sword. 

When a wound of the soft parts is accompanied by a similar 
affection of the subjacent bone, an immediate reunion of the 



OF NECP.OSIS. 157 

soft parts must not be attempted. Lint is to be gently intro- 
duced into the fissure, and the wound healed from the bottom; 
for a solid cicatrix of the soft parts cannot be expected until 
the wound in the bone is first cicatrized. 

If the bone of one of our limbs be cut quite through, as in the 
cases mentioned by La Peyronie, Warner, and others ; and if a 
piece of flesh remain undivided, which contains the principal 
vessels of the limb, it will be prudent to reunite the parts, and 
place the limb in the apparatus used in cases of fracture of the 
part. 

The time necessary for the reunion of the parts in cases of 
this nature is full as long as that in those of fracture, and the 
consolidation is effected in the same manner as in the former 
case. 



CHAPTER XIX. 



OF NECROSIS. 



THAT affection of bones by which a part of their sub- 
stance is deprived of the vital principle, has been termed 
necrosis: the affected part of the bone, in this case, bears a 
strict analogy to that of soft parts in which a gangrene has taken 
place. This disease was not distinguished from caries by the 
ancients, and it has been termed " dry caries" by some of the 
moderns. Necrosis and caries are, however, essentially dif- 
ferent. 

Osseous parts attacked by necrosis are absolutely deprived of 
the vital principle: but this is not the case when they are simply 
carious; for caries is an affection exactly analogous to foul and 
corroding ulcers of the soft parts. 

All the bones of the body are subject to necrosis, but some 
are more frequently attacked by it than others; the broad 



I58 OF NECROSIS. 

bones, for instance, and those which are but lightly covered 
with soft parts, such as the bones of the skull, the lower jaw, 
the clavicle, the scapulae, the humerus, femur, and tibia. The 
short bones are seldom attacked by it, but are much more sub- 
ject to caries. The affection may be either partial, or it may 
extend to the entire bone. Thus we find a long bone affected 
in some part of its length, or entirely diseased from one end 
to the other, and broad bones affected only in their external 
laminae, or in their entire substance. 

The middle portion of long bones, or that part of them 
which is most compact, least porous, and consequently least 
endued with the vital principle, is that which necrosis most ge- 
nerally attacks : the extremities of these bones, and in general 
all spongy bones, are much less liable to it. This disease never 
extends to the articulations, even when the whole diameter of 
the middle part of the bone is affected by it: the extremities 
covered with cartilage separate from the dead part of the bone, 
and if this be removed by nature or art, they unite with the 
ossified periosteum, which occupies the place of the separated 
portion. 

When the necrosis is superficial, the superior lamellae are 
separated from the rest of the bone; but this separation is al- 
ways preceded by a suppuration produced by the irritation given 
to the surrounding soft parts by the dead portion of bone. It 
is to be observed, that no part of the substance of the dead 
portion of bone goes to the formation of this purulent matter; 
for it seems to be not only incapable of furnishing matter for 
the formation of pus, but is entirely without the sphere of vi- 
tal action. 

If a broad bone, as the os frontis, for instance, be attacked, 
the skin over the affected part tumefies, becomes inflamed, and 
assumes a brown or violet colour; it grows gradually thinner, 
bursts at length, and gives issue to the purulent matter contain- 
ed under it. The necrosis of the bone is then ascertained by 
introducing a probe, which is found to pass on a rough and 
naked surface, if the affection of the bone really exist. 

In a case of complete necrosis of a long bone, the limb swells 
at the part affected, and a hard and painful tumour is formed 
on it. Abscesses form at various points, they burst, and their 
openings degenerate into fistula?. The discharge from these in 
the coinmencement is white and inodorous, but becomes se- 
rous and fetid in a short time. This matter is sometimes ab- 
sorbed in such quantity as to produce marasmus, hectic fever, 



OF NECROSIS, I59 

&c. In tfases of necrosis, in which the whole bone is affected, 
the periosteum separates from the portion of diseased bone, 
its vessels seem to take on a new action, a calcareous phosphate 
is deposited in its texture, it acquires hardness, and in time 
forms a cylinder, in which the dead part of the bone is in- 
cluded. This new bone, which is in fact the periosteum os- 
sified, is rough on its surface, and has but a distant resemblance 
to that which it replaces. Various holes are observed in it, 
through which the purulent matter and mouldering portions of 
bone escape, the fistulous openings in the soft parts being con- 
tinuations of these holes, and the muscles of the limbs are in- 
serted into it. 

The dead part, completely separated from the sound, and 
enclosed by the indurated periosteum, is called sequestra : this 
separation is perfectly analogous to that of mortified soft parts. 

The promptitude with which gangrened soft parts are sepa- 
rated, is much greater than that with which a dead portion of 
bone is detached; but this difference is to be entirely attributed 
to the state of the vital energy of the parts, which is much more 
considerable in one case than in the other. 

The causes of necrosis may be divided into internal and ex- 
ternal; the latter are blows, excessive pressure, imprudent ap- 
plications of caustics; as happened in the case of a woman who 
had caustic potash applied to an exostosis on the internal side 
of the tibia. But necrosis is most frequently produced by an 
internal cause, such as scrofula, or syphilis. In persons thus 
constitutionally affected, a blow or other external accident, may 
prove an exciting cause of the disease. 

By whatever cause produced, the following symptoms cha- 
racterize k: excruciating pains in the part affected, which no 
emollient nor sedative application can assuage. As there is no 
visible swelling in the commencement of the disease, these 
pains are frequently attributed to rheumatism. The pain 
which was felt at first but about the middle of the bone, extends 
towards its extremities,, if the bone affected be a long one : the 
part swells, the skin becomes inflamed, and the tumour, which 
was hard at first, grows soft in different parts, or abscesses 
form in it, which burst, and whose openings degenerate into 
fistulse. The surface of the bone, if not deep seated, as the 
tibia for instance, may be seen through this opening; in which 
case the nature of the disease may be ascertained beyond all 
doubt ; but an equal certainty may be had when the bone is 



l6o OF NECROSIS. 

covered by a great depth of soft parts, by the insertion of a 
probe. 

There is at first a copious discharge of purulent matter, but 
the quantity gradually diminishes, and splinters of dry bone, 
coloured, as if they had been buried a long time in the earth, 
come out with the pus. The disease may be said to be at its 
height at this period, for now the dead part is separated by the 
vital energy of the sound. By introducing a probe at this time, 
pieces of the bone are felt detached and loose. These symp- 
toms of necrosis, evident enough in affections of the long bones 
covered with thick muscles, are still more so in cases of flat su- 
perficial bones, as those of the skull for instance : in affections 
of the latter, the skin beeomes first thick, hard, and reddish - y 
but it soon bursts, and an ulcer is formed in it. 

The prognosis varies in this disease according to the bone af- 
fected, and the circumstances with which it may be compli- 
cated. 

If the disease be confined to the surface of a flat bone, or 
though it should affect it quite through, it is not very dange- 
rous, and nature alone effects the cure. If the assistance of art 
be necessary, it is only in combating the disease of the system. 
However, if there be a large surface affected, and if the intro- 
duction of instruments for the purpose of extracting the splint- 
ers be difficult, the prognosis becomes more unfavourable. Ne- 
crosis, when confined to the surface of the middle part of long 
bones, is equally free from danger as in the former case, and 
nature alone effects a cure. But the prognosis is far different 
Tvhen a large portion of the bone is affected, and when this 
portion is contained in the cavity of the cylinder formed by 
the ossified periosteum; for though nature has been able to se- 
parate it, yet the assistance of art is necessary to remove it 
from its osseous covering. 

In cases of necrosis, in which the dead bone is entirely in- 
cluded in that newly formed, the prognosis may vary according 
to the state of the soft parts of the limb, the age and strength of 
the, patient, and the form of the new osseous substance. The 
tumefaction of the limb may be excessive, the fistulse numerous, 
the suppuration abundant, and the strength may be reduced by 
colliquative diarrhoea and hectic fever. In such circumstances 
the danger is much greater than if the suppuration were trifling, 
the patient young and healthy: and the danger will be still less 
if the new bone be naturally perforated, so as that the old one 
may be drawn out. 



OF NECROSIS. l6l 

The surgeon, whose art is so useful in most diseases of the 
bones, can, in cases of necrosis, be but a simple spectator of 
the operations of nature, which are frequently successful: it 
may be said with truth, that necrosis proves the efficacy of na- 
ture, and the insufficiency of art. Art can assist nature only 
in removing that part of the bone which the vital principle has 
abandoned j as has been amply shewn in the Memoirs of the 
Academy of Surgery, in David's Treatise on Necrosis, and 
more particularly in a Latin work on that disease, by M. Weid- 
man. If the necrosis be superficial, or not very extensive, na- 
ture alone is sufficient to remove effectually the diseased part; 
but art assists in cases of deep-seated necrosis, in which the 
dead bone, after its complete separation, is enclosed in the 
new. 

L The treatment adapted to the necrosis of broad or flat bones, 
or that of long bones when the disease is confined to the sur- 
face of their middle part, is very different from that which 
should be followed when the necrosis has seized the entire body 
of the latter. We shall therefore explain these different modes 
of treatment successively. 

When one of the large bones of the skull is attacked by necro- 
sis in any part of its surface, nothing is to be done until exfolia- 
tion takes place. The progress of this process is marked by an 
inflammatory circle round the part to be separated, by a fissure 
which succeeds, and marks the same circumference, and which 
grows wider and wider every day. If at this time the diseased 
portion be struck with a probe, a noise is heard which indi- 
cates an empty space under it : it becomes loose soon after, and 
may be very easily removed. The separation of it may be ac- 
celerated by stirring it every day, but it is useless to apply any 
instrument for the purpose of thinning it; for the exfoliating 
of a thick lamella is just as easy as that of a thin. The use of 
the trepan is equally inapplicable for this purpose, as it is im- 
possible to know beforehand to what depth the exfoliation will 
take place, and if that depth be not entirely taken off, the 
slightest lamella which remains will be just as troublesome as if 
the whole remained: nature will require as much time to se- 
parate it, as if it had been much thicker. We have already 
pointed out the inutility of perforating the affected part of the 
bone, with the intention of facilitating the exfoliation. We 
have also remarked, that unctuous and emollient bodies are 
"better topical applications than spirituous irritating substances, 
such as tinctures of aloes and mvrrh; or than caustic, which, 
2.1 



l6l OF NECROSIS, 

by irritating the subjacent parts, often causes the disease to ex- 
tend. 

It is plain that the topical affection will continue to extend 
incessantly, when it depends on a constitutional disease; there- 
fore, while nature tends to remove the former, it will be neces- 
sary to oppose appropriate remedies to the general disease, 
whether venereal, cancerous, scrofulous, or scorbutic. 

If one of the bones of the cranium be affected with necro- 
sis, and the brain be compressed by pus, it will be necessary to 
use the trepan, as advised by Quesnai, in order to remove the 
pus accumulated on the dura mater. The trepan is not applied 
in this case against the disease itself, but against a very dange- 
rous consequence of it. In stirring the piece, in order to ac- 
celerate its separation, care must be taken not to break it, as 
the extraction of the remaining portion, generally covered with 
soft parts, might be difficult. It is found necessary in many 
cases to make use of a spatula, or some such instrument, to 
disengage the splinter from the granulations which encroach on 
its surface, and take root as it were in its inequalities: this may 
take place to such a degree, that it may be sometimes necessa- 
ry to make an incision into the soft parts, in order to extract 
more readily the portion of dead bone. 

When the piece is extracted, the disease is reduced to the 
state of a simple wound. The granulations which arise from 
the diploe, or dura mater, when any of the bones of the skull 
has exfoliated, become the foundation of a solid cicatrix. The 
bone always remains thin in that part; and it has been found 
necessary to protect the part of the cranium, from which an ex- 
foliation of this kind took place, with a piece of leather or 
pasteboard. 

When the exterior lamellae of a long bone are affected with 
necrosis, the treatment is precisely the same. If it be ascer- 
tained by the introduction of a probe through a fistulous open- 
ing, that an exfoliation of the bone has taken place, an incision 
must be made for the purpose of extracting the exfoliated piece. 
But when this disease affects the whole of a cylindrical bone, 
and when the periosteum is ossified around the diseased bone, 
it will be necessary to acquire the greatest certainty of the com- 
plete separation of the decayed portion from the new one. In 
order to ascertain this, we attend to the duration of the disease,. 
but principally to the motion that may be communicated to the 
decayed portion, by introducing a probe through one of the 
fistulous openings. It happens sometimes that, in moving the 



OF WECROSIS. 163 

limb, a noise may be heard from the collision of the decayed 
bone against the parietes of the new one. 

When nature has done her duty, the assistance of art must 
be called in to complete the cure; but the extraction of the 
dead bone is an operation of a painful and hazardous nature, 
and should not be undertaken without reflecting very seriously 
on its probable consequences, and on those of the disease if left 
to itself. The operation is extremely difficult when the diseased 
bone is covered with a great number of very thick muscles, as 
the femur for instance. In that case saving the patient's life 
alone, endangered by the excessive suppuration and absorption 
of the pus, is the only thing that can induce the surgeon to 
perform the operation ; the patient being at the same time firmly 
resolved to suffer any thing for the chance of saving his life. 
It will be necessary to try if the disease has extended as far as 
the articulations, in which case it would be better to ampu- 
tate, than attempt to save the limb. 

The operation being decided on, the following is the method 
to be followed. It is commenced by laying bare the affected 
bone on the side least covered with soft parts, and on which 
there will be the least danger of meeting principal nerves and 
blood-vessels. Thus the inferior and external part of the hu- 
merus is that in which the incision should be made when this 
bone is affected; when the disease is seated in the cubitus, the 
internal side of the fore arm; and when in the radius 3 its ex- 
ternal side; the lower part and external side of the thigh, when 
the femur is affected; and the anterior and internal side of the 
leg, which is covered by the skin only, when the tibia is the 
part diseased. This part of the operation does not consist of a 
simple incision, but of two semi-elliptic incisions, the parts be- 
tween which are to be completely removed. This practice is by 
much preferable to the use of caustic, the action of which is 
tedious, and might extend to the regenerated bone, and de- 
stroy its texture. If the patient be timid, caustic may be used, 
but the greatest care must be taken to confine its action to the 
soft parts. If the hemorrhage be great, and the patient's suf- 
fering intense, the wound may be washed, and filled with lint; 
and the rest of the operation deferred to the following day. 
After having laid the bone bare, two or three pieces are to be 
cut out from its inferior part by means of a trepan; the inter- 
vals which separate the holes are then forced out with a chisel 
and mallet; and a passage being thus opened, nothing remains 
hut to extract through it the decayed bone, which is found t* 



164 OF CARIES. 

lie without any connexion in the inside. The deep wound pro- 
duced by this operation is then filled with lint, and dressed in 
future like a simple wound, which is to be healed by suppura- 
tion; but the recovery is always slow. If the length of the de- 
cayed bone be inconsiderable, the perforation may be made in 
the middle part of the new one. But when that is not the 
case it will be advisable to trepan the inferior part of the bone, 
as a less opening will suffice there than in the middle part, and 
as the situation is more favourable for the evacuation of the 
pus. 

Notwithstanding the prodigious disorganization and suppu- 
ration necessarily attendant on this operation, it has however 
been followed with success in some instances related by David. 

We are of opinion that few cases occur in which it is neces- 
sary to perform this operation; that the reasons for undertaking 
it are seldom conclusive; and that it should not be had recourse 
to without the maturest deliberation. 



CHAPTER XX. 



OF CARIES. 



THE more we advance in the study of diseases of the 
bones, the greater is the obscurity in which we find them 
involved; and if there be any of them, the nature of which 
may be said to be totally unknown, it is certainly that which is 
our present subject of consideration. 

The clearest way in which we can convey an idea of caries, 
is, by comparing it to those ill conditioned ulcers of soft parts, 
which are symptoms of a diseased state of the system. But 
the idea ^given by this comparison is not sufficiently comprehen- 
sive; we shall therefore endeavour to supply its deficiency by 
an exact detail of the appearances of bones affected with this 
disease* 



OF CARIES. 165 

Every part of the osseous system is liable to caries ; but it has. 
been observed, that spongy bones are oftener attacked by it 
than those that are compact; thus the vertebrae, astragalus, 
and other bones of the tarsus, those of the carpus, the sternum, 
and the extremities of long bones, are the most frequent seat 
of this disease. For a similar reason the bones of young per- 
sons are more subject to it than those of persons advanced in 
life. 

Very little information is to be acquired by reading the works 
of the authors who have treated of this disease. Almost all of 
them have confounded it with necrosis, which they termed dry 
caries ; others have considered it to be the same as exostosis. For 
pur part we are of opinion that there is only one species of this 
disease, but that this is susceptible of several modifications. 
The substance of a bone affected by it becomes so soft, that the 
end of a blunt probe may be easily forced into it.- The open- 
ings with which the bone is perforated, are filled with fungous 
flesh, which bleeds from the slightest cause: there is a dis- 
charge of a blackish serum from these perforations, which has 
at all times a disagreeable smell, but which is particularly fetid 
when exposed to the contact of the air. Necrosis and caries 
differ in this particular respect: in the former, the bone affect- 
ed is entirely deprived of the vital principle ; but in the latter 
this principle exists, and the disease consists of a morbid action, 
by which the osseous texture is destroyed. 

The causes of caries are distinguished into internal and ex- 
ternal; the internal are the most frequent, because a contusion 
or external violence is apter to produce necrosis than caries. It 
may happen, however, that a blow on a spongy bone shall oc- 
casion a caries of it, by producing an extravasation of blood or 
medullary juice, which cannot be afterwards taken into the 
system by absorption. 

Abscesses are said to occasion sometimes a caries of the 
bones, over which they take place; and we are told, that the 
existence of the morbid state of the bone may be ascertained 
by introducing a probe to the bottom of the abscess. 

Conformably to this theory, it has been laid down as a rule, 
that abscesses situated over bones should be opened at an 
early period, in order to prevent any disorder of the bone- or 
periosteum from the stagnation of the purulent matter. But if 
abscesses formed over certain bones, as, for instance, over the 
anterior face of the tibia, or mastoid process of the temporal 
fcone, be frequently accompanied with caries, the latter is the 



166 OF CARIES. 

cause, and not a consequence, of the abscess. Pus, which is a 
bland, unctuous, and inodorous fluid, never attacks the soft 
parts with which it is in contact, until its qualities are changed 
by exposure to the air. When an abscess forms in the anteri- 
or part of the parietes of the abdomen, the peritoneum of that 
part, naturally a thin membrane, instead of being corroded, 
becomes thick and strong enough to resist the effusion of the 
pus into the cavity of the abdomen. The periosteum becomes 
thickened in similar circumstances, when the abscess is a con- 
sequence of an external injury. 

We may conclude, then, that caries is seldom produced by 
an external cause; and that most frequently a blow or external 
injury, when followed by that disease, has acted only as an 
exciting cause, a disposition to it having pre-existed. There 
is every reason to believe that it may be ascribed in almost all 
cases to a disease of the system, such as scrofula, lues, scurvy, 
or even cancer. 

Scurvy diminishes the energy of the contractile fibre, and 
diffuses a principle of dissolution in the solids ami fluids. The 
blood rendered more fluid by it than natural, oozes through 
the pores of its small vessels: spots or ecchymoses manifest 
themselves, first in the parts in which the circulation is most 
languid, as on the hands and feet: the muscles become soft and 
painful; the gums swell, and separate from the alveolar pro- 
cess: the periosteum may become tumefied in like manner, 
and lose its connexion with the bone affected with caries. 

Scrofula attacks the spongy part of bones and the lymphatic 
system. A caries from this cause is very frequent in the tarsus, 
carpus, elbow, and knee; but it is always preceded by a white 
swelling. 

The venereal disease is sometimes a cause of caries, though 
its action on the osseous system more generally produces ne- 
crosis or exostosis. However, when it attacks the bones of the 
nose, it produces a caries of them, by which they are consu- 
med, and the face sadly disfigured. The bones of the palate 
«re sometimes destroyed in the same manner, and by the same 
cause. 

In cancers of the mammae, the sides of the sternum are of- 
ten found carious; which proves that cancerous ulcers may, 
as well as the preceding diseases, occasion a caries of the bones 
in their neighbourhood. 

Nothing can be easier than to ascertain the existence of a 
superficial caries; and when the affected bone is deep-seated 3 



OF CARIES. 167 

it may be discovered by introducing a probe; for if the bone 
be carious, the probe may be easily forced into its substance. 
But bones which we cannot readily come at may be carious, in 
which case the diagnosis is somewhat more difficult; however, 
if a fistula, from which a fetid blackish matter flows, be direct- 
ed towards a bone, and if the surrounding soft parts be at the 
same time turgid and indurated, there is every reason to appre- 
hend a caries. The black colour of the discharge is, however, 
equivocal; because, as remarked by Ambrose Pare, it may be 
occasioned by a bit of agaric or other foreign body introduced 
into the wound. It will be prudent, therefore, in dubious cases, 
to trust chiefly to the history of the disease. 

If a person affected with a certain constitutional disease, feel 
deep-seated and acute pains in any of his bones ; and if the 
pained part swell, and become the seat of an abscess, from 
which a purulent matter of a bad quality flows, there is every 
reason to believe that the bone affected with pain is carious. 
Inert abscesses are attended with nearly the same symptoms^ 
with this difference, that they are not preceded by pain. Ca- 
ries occasioned by syphilis affects most commonly the tibia, os 
frontis, ossa nasi, ossa palati, and sternum. Whenever, there- 
fore, any of these bones become carious, whilst the person la- 
bours under syphilis, there is just ground for concluding that 
the caries is a symptom of the venereal affection. 

A caries of the vertebrae is known by peculiar symptoms, 
among which a paralysis of the inferior extremities, and the 
formation of abscesses in the groin, verge of the anus, or lum- 
bar region, are the most remarkable. 

The prognosis is more unfavourable in cases of caries of spon- 
gy bones, than in those of a similar affection of compact ones, 
thus there is not so much to be apprehended when the bones 
of the cranium or the scapulse are affected, as when the extre- 
mities of long bones are similarly diseased. Caries of the 
bones of the carpus and tarsus is also very dangerous. The evil, 
on account of these bones being in such close contact, extends 
from one to the other; and when one of them becomes carious, 
it is very difficult to stop the progress of the disease without am- 
putating the limb. 

This operation is often the only resource in our power 
against caries of short bones, or of the extremities of long 
ones; and we are even deprived of this when the bone affected 
with it is deep-seated: thus caries of the head of the femur, 
or of the cotyloid cavity, cannot be remedied by this operati- 



l63 OF CARIES. 

on. The same may be said of caries of the spine, also named 
gibbosity, in which, as well as in the preceding case, our 
treatment must be merely palliative. 

Caries from an external cause is less dangerous as well as less 
frequent than that from an internal; and that resulting from 
an internal disposition is much more dangerous when it pro- 
ceeds from a scrofulous or cancerous diathesis, than from a ve- 
nereal or scorbutic; for some efficacious remedies against the 
latter are known; but cancer and scrofula resist all the reme^ 
dies with which we are as yet acquainted. It is also more dan- 
gerous to old than to young persons, not that its progress is 
not more rapid in the latter, as already mentioned, but because 
nature is more capable of limiting its ravages in youth than in 
old age. Finally, the prognosis is further influenced by the 
extent of the disease, the patient's strength, and state of the 
neighbouring soft parts. 

There is, perhaps, no disease in which the indications of 
cure are more vague than in caries, and none in which the 
treatment is less regular. The ancients prescribed unctuous or 
relaxing applications, but they preferred acrid irritating sub- 
stances, such as the powder of euphorbium, tincture of aloes 
and myrrh, oil of turpentine, mineral acids, caustic alkali, or 
even the actual cautery. Monro, Tenon, and, in imitation of 
them, some modern practitioners, have preferred the use of 
unctuous and emollient applications; but, in order to discover 
the preferable mode of treatment, it is necessary to take a 
close view of the evil against which it is to be directed. We 
must then consider, that a bone affected with caries is a prey 
to a morbid action of its own parts, and that this action creeps 
from one part to another, and pervades the whole with great- 
er or less rapidity, if art does not come to the assistance of na- 
ture to arrest its progress. 

If the caries be produced by some affection of the system, 
this should be ascertained and combated with appropriate re- 
medies. Thus the use of mercurial and sudorific medicines ar- 
rests the progress of caries proceeding from the venereal dis- 
ease, and aids nature in separating the unsound from the sound 
part. The use of spirituous drinks, vegetable diet, and acids, 
removes at once scurvy and the caries, to which it had given 
rise, &c. &c. But if it has been occasioned by an external 
cause, or if it has remained after the internal one has been re- 
moved, so as to be reduced to the state of a mere topical af- 
fection, its progress may be arrested, and the separation of the 



OF CARIES. 169 

diseased parts facilitated by the use of such substances as stimu- 
late the parts, or such as absorb and neutralize the fluids which 
tend to propagate the morbid action. Thus the desiccation of 
a carious ulcer has been effected by the use of an absorbing 
powder and pledgets of lint that had been dipped in tincture of 
aloes and myrrh. 

If these remedies be found ineffectual, recourse must be had 
to more active ones; a pledget of lint dipped in a solution of ni- 
trate of silver, may be applied on the carious part, and renewed 
every day. This portion of the bone is by this means, quickly 
dried up, and reduced to the state of a simple necrosis; the pro- 
pagation of the morbid action is arrested, and nature effects a 
separation of the diseased parts. It will not be amiss, however, 
to move frequently the dried piece, and it may be necessary to 
prevent the fungous flesh from spreading so as to impede the 
exfoliation. The ulcer heals after the exfoliation has taken 
place, and the cicatrix is more or less deep, and of a red co- 
lour, not blackish and livid, as a cicatrix formed over a dis- 
eased bone. 

If the caries be very humid, that is, if a great quantity of 
sanies flow from it, these remedies even the murcurial nitrate, 
will be of no effect. The sanies washes the pledget, and di- 
lutes the caustic so much, that its action is considerably en- 
feebled. Caustic pot-ash would be subject to the same incon- 
venience. In these cases, the actual cautery is a remedy to be 
preferred to all others: by its action the carious part is in an 
instant reduced to the state of an inorganic dry substance, and 
the caries thus converted into necrosis. This remedy is appli- 
cable to every case of humid caries where the surrounding soft 
parts have not a manifest tendency to cancer. Sometimes, 
however, the soft parts surrounding a carious bone have that 
tendency in so advanced a degree, that the actual cautery 
would necessarily occasion the developement of that morbid 
state. The general rules to which the use of the actual caute- 
ry may be reduced are as follow: 

In the first place, all the carious part of the bone must be 
laid bare, whether by cutting away the soft parts, or destroy- 
ing them by caustic. The latter method being tedious, incon- 
venient and uncertain, should not be used unless when the pa- 
tient will not submit to the use of the knife. The bone being 
in this manner laid bare and scraped, the surgeon provides him- 
self with several cauterizing irons of the same form, because 
the application of one is seldom sufficient. It will also be ne- 
22 



I70 OF CARIES. 

cessary to provide a number of canulx when the cautery is to 
be applied on a bone from about which the soft parts cannot 
be completely raised, as, for instance, on the os coccygis, or 
sacrum: by means of these canulae, the hot iron can be intro- 
duced without injuring the soft parts. In every case it will be 
necessary to protect the surrounding parts as much as possible 
from the action of the cautery. 

The iron, whatever may be its size, should be heated white, 
as the hotter it is the more rapid and less painful is its action* 
On the instant of its application, a black thick smoke rises 
from the surface of the burning bone, the smell of which re- 
sembles exactly that of burning horn: the great quantity of 
sanies quickly diminishes the heat-, for which reason a second 
is to be immediately applied with the same precautions; and a 
third, if the two preceding have not burned deep enough. Care 
should be taken to extirpate the disease by burning every part 
that is affected; and if the use of the cautery has not always 
had the success expected from it, the failure of it is to be attri- 
buted to the timidity of the operator. A carious bone becomes 
worse by the application of the actual cautery, if the evil be 
not entirely rooted out; just as a cancerous tumour becomes 
irritated, and makes a more rapid progress, if imperfectly cau- 
terized. 

The actual cautery acts by evaporating the noxious fluids in 
which the carious bone was immersed; by changing the caries 
into necrosis, and by irritating the subjacent sound parts, and 
exciting that action of the vessels by which the dead part of 
the bone must be thrown off. 

It is almost superfluous to remark here, that this operation 
cannot be undertaken with any hopes of success, if the inter- 
nal cause of the caries still exist. 

Let us examine, in the next place, the modifications of this 
general treatment, which may be required for any particular 
bone. 

The bones of the cranium are often affected with the vene- 
real caries, of which pain and tumefaction of the part are the 
first symptoms. The tumour augments and becomes soft, and 
on bursting spontaneously, or being opened by an instrument, 
a thin, serous, purulent matter flows from it. If a probe be 
now introduced into the wound, the bone will be found to be 
carious. The first remedies must, in this case, be directed 
against the disease of the system. The use of caustics is en- 
tirely inadmissible; for should their action extend too far, the 



OF CARIES. I7I 

worst consequences might result from it, such as inflammation 
of the brain or its membranes. It is better to remove the dis- 
eased part of the bone by means of a trepan. In laying the 
bone bare, as much of the integuments should be preserved as 
will be sufficient to cover the wound, which precaution will 
accelerate the cure. 

It is particularly in caries of the mastoid portion of the tem- 
poral bone that the use of the cautery is admissible. Abscesses 
are frequently formed in consequence of caries in that part of 
the bone; these burst, and their openings degenerate into fis- 
tulas. If a carious state of the bone be discovered by the in<- 
troduction of a probe, the bone is to be laid bare, and the 
cautery applied, and repeated until the caries is completely de- 
stroyed. The mastoid portion of the temporal bone is spongy 
in its texture, and sufficiently thick to protect the brain and 
its membranes from the action of the cautery. Tenon and 
Chopart practised this operation with success. 

The bones of the face, and those of the nose and palate, 
are very subject to the venereal caries; but this affection of 
them disappears by removing the general disease of the sys- 
tem. The parts, however, remain deformed in consequence 
of the lpss of substance. 

The collection of matter which frequently takes place in the 
antra maxiilaria sometimes occasions a caries of the bones 
which form these cavities. In these cases, all that is necessa^- 
ry is to perforate into the cavity through the alveolar process; 
for as soon as the collected matter gets a free passage, the fistu- 
lae, if any have been formed externally, dry up, the carious 
part of the bone separates and comes away, and the wound in 
the soft parts heals at the same time. 

The caries of the os unguis, which is sometimes complica^- 
ted with fistula lachrymalis, is remedied by the different ope- 
rations performed for giving a free passage to the tears. The 
scorbutic caries of the alveolar process is removed by the same 
remedies as the general disease. 

As soon as the system is perfectly clear of the scorbutic dia- 
thesis, the bone exfoliates, and the gums acquire their natural 
firmness. Detersive gargles may be used to accelerate this ter-r 
mination. 

Caries of the spine is attended with much worse consequen- 
ces; the gibbosity and secondary abscesses of which it is the 
cause, generally prove fatal. When the anterior part of any 
of the vertebrae becomes affected with caries in consequence of 



172- OF CARIES. 

a diseased state of the system,* the purulent matter that h 
formed makes its way into the cellular texture which lines the 
anterior part of the spine, and descends by its own weight 
along the vessels to the superior part of the pelvis; whence it 
sometimes flows along the external iliac arterv into the groin, 
where it forms a tumour. At other times it descends into the 
pelvis along the hypogastric vessels, and forms tumours about 
the anus; finally, it may penetrate through the fibres of the 
lumbar paries of the abdomen, and manifest itself at the 
posterior part of the pelvis. These accumulations of pus, or 
svmptomatic abscesses, are always preceded for a longer or 
shorter time, by pain in some part of the spine; and the tu- 
mour forms without any antecedent or co-existing inflamma- 
tion of the part. The abscess acquires insensibly an enormous 
volume, and the pus makes its way into the cellular texture of 
the limb of the affected size: its side may, however, be dimi- 
nished by compression, and its contents seem to retreat into 
the abdomen. The integuments inflame at length, and burst 
in the most projecting point; a thin purulent matter flows from 
the opening; it is, at first perfectly inodorous, but soon ac- 
quires a fetid smell, and changes colour. This alteration in 
the qualities of the pus seems to be owing to the contact of the 
air; but so great is its fetidness, that the patient's existence is 
loathsome to himself, and insupportable to others: the absorp- 
tion of this matter brings on slow fever, diarrhoea, colliquative 
sweats, and marasmus, and the patient is at length cut off. As 
the fatal event is distant in proportion to the retardation of the 
opening of the abscess, and to its protection, when opened, 
from the contact of the air, it is evident that it should not be 
opened as long as it can be avoided; and that when it becomes 
absolutely necessary, the opening should be as small as possi- 
ble, and the air carefully excluded. Both these purposes are 
answered by making the opening with a seton needle, and 
leaving the seton in the abscess; but as this is not the pro- 
per place to give a full account of the treatment of these ab- 
scesses, we shall proceed to the consideration of that affection 
of the spine which has been termed gibbosity. 

This affection does not always depend on a caries of the ver- 
tebrae; and when it arises from that cause, the caries is then of 
a peculiar nature, being almost dry, and unattended with the 

* Masturbation is frequently a cause of this caries, Citizen Boyet^s 
practice has furnished him with many examples of it. 



OF CARIES. 173 

formation of abscesses. The affected vertebra, filled with holes, 
and as if moth-eaten, yields to the incumbent weight; the body 
of that which is superior to it descends, while its spinous pro- 
cess ascends and projects under the integuments. A never-fail- 
ing symptom of this disease is a paralysis of the inferior extremi- 
ties, rectum, and bladder. If the derangement take place in the 
vertebrae of the neck ^ which is very rare), the patient is soon 
destroyed in consequence of the paralysis of the muscles by 
which respiration is performed. When the derangement of the 
vertebra is gradual, the progress of the caries being slow, a 
numbness is first felt in the lower extremities, which is the pre- 
cursor of paralysis: but the bladder, rectum, and inferior ex- 
tremities, soon become paralytic, and the patient is confined to 
his bed until relieved by death. Gibbosity from this cause is 
fatal to adult persons. That observed in young children is dif- 
ferent in its consequences, and seems to proceed from a diffe- 
rent cause; that is, from a collapse of the vertebrae before they 
have acquired their full consistence, rather than from a carious 
affection. In cases of this kind, a perfect recovery has been ef- 
fected by applying caustic to the sides of the tumour, by burning 
moxa, or rubbing irritating substances on the spine, and by- 
joining to these means the use of the cold bath and a tonic re- 
gimen. 

When the same person is at onee affected with gibbosity and 
secondary abscesses, there is no chance of his recovery. 

Enough has been said to shew the extreme danger of caries 
of the spine, and the insufficiency of art in the treatment of it. 

The spongy texture of the sternum renders it very liable to 
be effected with caries, the progress of which is, for the same 
reason, more rapid in it than in any other bone. The soft parts 
which cover the carious portion of bone, become inflamed, and 
abscesses form, which burst in a little time. The state of the 
bone may now be discovered by introducing a probe through 
one of these openings; and very often, besides the caries, it is 
found that an effusion of pus has taken place into the anterior 
part of the mediastinum. In which cases the probe penetrates 
more or less into the cavity of the thorax, and the pus con- 
stantly flows in greater or less quantity through the fistula : it 
most frequently happens that the stagnation of the pus, the mor- 
bid changes which it undergoes, and the effects of its absorption 
in this state into the system, render it necessary to apply the 
trepan to the sternum. Among the bad consequences of caries 
of the sternum, may be reckoned the destruction of a part of 



174 OF CARIES. 

the pleura, or even of the pericardium: although in the great- 
er number of cases the former of these membranes becomes 
thicker in the part corresponding to the abcess, and sometimes 
cartilaginous, or even bony. The pulsation of the heart be- 
comes very manifest by the destruction of the pericardium. 
Harvey profited of a case of this nature to shew this phenome- 
non to the King of England, and several other persons. But 
whether the thickening of a part of the pleura, or the destruc- 
tion of a portion of the pericardium, be the consequence of the 
abscess, the cavity of the thorax, properly so called, is not 
opened in either case. 

The treatment of caries of the sternum varies according to 
the circumstances of the case ; it may be remarked however, 
that the particular structure of the bone renders a caries of it 
extremely dangerous. A spontaneous recovery is scarcely to be 
expected, although the following case furnishes an instance of 
it. A person convalescent from another disease, was suddenly 
seized with an acute pain behind the sternum; respiration be- 
came difficult, and a fever supervened. At length a tumour, 
with fluctuation, manifested itself a little lower than the middle 
part of the bone. A small portion of caustic pot- ash was applied 
to this tumour; and on dividing the crust formed by it, a great 
quantity of the pus flowed out and the patient felt much re- 
lieved. After opening the abscess, the suppuration gradually 
diminished, and the fistulous orifice was closed up in the space 
of a few months; during which time however, the patient re- 
sided in the country, and used a nourishing diet and tonic me- 
dicines. It ought to be remarked, that it is possible that the 
abscess may not, in this ease, have proceeded from a caries of 
the sternum; and that the pus collected in the anterior medias- 
tinum may have made its way outward through the opening 
which is often found in this part of the sternum. 

The treatment of caries of the sternum does not differ from 
that which has been already generally described. Particular 
care must be taken however, that in applying caustics, their 
influence may not extend to the organs of respiration. But 
when instead of caustics, cutting instruments are used, the part 
affected, however extensive, should be totally removed. This 
operation is not attended with great danger, because the inter- 
nal mammary artery, if opened, can be easily taken up. After 
the bone has been removed, the pleura, corresponding to the 
empty space, will be found to thicken in that part, and to ac- 
quire a cartilaginous hardness, so as to replace, in some degree, 



OF CARIES. 175 

the bone which has been destroyed. However, after the 
wound is completely healed, it will be prudent to cover the 
part with a piece of pasteboard or leather. If the carious part 
cannot be totally removed, it will be necessary to make two 
perforations in the lower part of the sternum, in order to give 
a free passage to the purulent matter. Though the disease will 
not be radically removed by this means, yet the sufferings of 
the patient will be considerably alleviated. 

Caries of the ribs, or that of the bones of the pelvis, offers 
nothing particular, it is to be remarked, however, that when 
the posterior ends of the ribs, or the anterior face of the sa- 
crum, are affected, secondary abscesses may take place as in si- 
milar affections of the vertebrae. Caries of the sacrum often 
succeed a gangrene of the soft parts which cover its convex 
side: in which case it will be necessary to wait a spontaneous 
exfoliation; or if nature does not appear adequate to that ope- 
ration, and if a great quantity of fungous flesh be found to 
grow up through the carious bone, it will be necessary to apply 
the actual cautery, according to the rules already laid down. 
Liquid caustics are improper in this case, because by passing 
the large cancelli, they might penetrate to the sound parts of 
the bone, and occasion a necrosis of it. 

Caries of the different parts of the iliac bone, and particu- 
larly of the cotyloid cavity, shall be treated of in the article 
on secondary or spontaneous luxation of the femur. 

Caries of the extremities of long bones, as it usually accom- 
panies white swellings of the articulations, will be considered 
in treating of the latter affections. 



176 



CHAPTER XXL 



OF EXOSTOSIS. 



A SWELLING may take place in bones as well as in 
other parts, from a determination and accumulation of 
fluids; but there is a particular kind of tumour which forms 
on their surface, and which is denominated exostosis. This 
name, however, comprehends different species, which should 
be considered as distinct; thus that affection which has been 
described under the name of spina ventosa, or osteosarcoma, is a 
distinct disease: there is also another species of exostosis diffe- 
rent from all others, and which consists principally in a thick- 
ening and tumefaction of the periosteum; it may very proper- 
ly be termed periostosis. Exostosis, properly so called, is rare, 
the reason of which is easily perceived from the consideration 
of the hardness and consistence of the texture of the bones, 
the small number of their vessels, and consequently the diffi- 
culty of a copious influx of humours into them. 

The tumefied portion of bone acquires in some cases sueh a 
hardness, that no remains of a fibrous structure can be distin- 
guished in it, and it absolutely resembles ivory; in other cases 
it is spongy; and finally it may be composed of osseous and 
fleshy parts; this latter variety resembles very much spina ven- 
tosa. 

The bones most frequently affected with exostisis are the 
broad bones of the head, the lower jaw, sternum, humerus, 
radius, cubitus, the bones of the carpus, the femur, and tibia. 
There is, however, no bone of the body which may not be- 
come the seat uf this disease, and the affection may extend to 
a greater or less portion of it. It is not uncommon to find the 
broad bones of the cranium affected with exostosis in their 
whole extent; the ossa parietalia, for instance, sometimes ac- 
quire an inch in thickness from this morbid affection. 

In most cases, however, the exostosis rises from the surface 
of the bone, and manifests itself as a hard round tumour. It 
sometimes appears towards the extremities of long bones, and 



OF EXOSTOSIS. 177 

at other times, more or less, near their middle part; and it is 
remarked that exostosis originating from a venereal cause are 
found principally on compact bones, and such of these as are 
but lightly covered with soft parts, as those of the cranium 
and face, and the tibia at its internal side; whilst, on the con- 
trary, those arising from a scrofulous diathesis appear on the 
spongy extremities of long bones, and on short ones of a simi- 
lar texture. These two diseases are almost the sole causes of 
this topical affection of the bones. A cancerous or scorbutic 
diathesis seldom occasions it. They more commonly produce 
caries, by effecting a separation of the periosteum from the 
bone. It must be remarked, however, that exostosis and ca- 
ries have the greatest affinity with one another; as is evident 
from the greater part of exostoses terminating in caries. J. L. 
Petit pointed out this analogy by a detailed comparison of the 
two diseases. The conversion of exostosis into caries takes 
place particularly in spongy bones, and in persons affected with 
scrofula. The ivory exostosis never terminates in caries. 

Exostosis proceeds very rarely from an external cause, such 
as a contusion, though such a consequence is not impossible. 
In most cases it is produced by an internal disease, and princi- 
pally by lues venerea, or scrofula, as already mentioned. 

An enlargement of the extremities of long bones, that of 
the whole substance of short ones, joined to a swelling of the 
glands of the neck, a delicacy and whiteness of the skin, a 
fulness of the face, and tumefaction of the point of the nose 
and upper lip, are marks of a scrofulous diathesis. 

The osseous system is attacked by the venereal disease only 
in the advanced stages of that disorder. The formation of ex- 
ostoses from this cause is generally preceded by dull pains, 
which appear to be deep-seated, and which are generally most 
severe during the night. 

An exostosis is always hard, but varies in size, and may be 
indolent or painful. By these marks, and by its firm adhesion 
to the bone, it may be always distinguished from every other 
kind of tumour. But if, on the contrary, the enlargement 
takes place in a short bone, and if its hardness, though consi- 
derable, be somewhat less than that just described, on which 
the finger can make no impression, it is probably a periostosis; 
which is by no means an uncommon symptom of the venereal 
disease. It is sometimes impossible to ascertain the existence 
of an exostosis before the patient's death; such was the case of 
an individual whose parietal bone had been found, after death, 
23 



178 OF EXOSTOSIS. 

to be three times thicker than natural. A similar case is rela- 
ted in the Memoirs of the Academy of Dijon. In this instance 
the person died from an exostosis on the internal side of the 
os pubis, which by pressing on the neck of the bladder pre- 
vented the passage of the urine, or the introduction of a ca- 
theter. 

It is possible that the head of a luxated bone may be mista- 
ken for an exostosis: this was the case with a young man 
whose clavicle was dislocated at that end of it attached to the 
sternum. The tumour formed by the end of the displaced 
bone, was mistaken for an exostosis, and was treated as such; 
but the inefficacy of the treatment induced the patient to ap- 
ply to Desault, then head surgeon of La Ckarite. This prac- 
titioner recognized instantly the luxation outward of the clavi- 
cle. It is also possible, that the enlargement of the ends of 
bones of rickety persons may be mistaken for exostosis; but 
though this kind of enlargement does not constitute a real ex- 
ostosis, yet it cannot be denied but that some analogy does ex- 
ist between them. Another species of tumour which might be 
mistaken for an exostosis, is that formed by fungous excrescen- 
ces growing from the dura mater, which, after having destroyed 
a part of the bones of the cranium, protrude externally; but 
the real nature of these may be discovered by an attentive ex- 
amination of their consistence and progress, and by attending 
to the pulsation of them, which is evident and synchronous 
with those of the heart. 

The effects of exostosis may be divided into general and 
particular: thus the swelling is accompanied by a sense of 
weight ; pain is produced by the morbid action, and the affect- 
ed part is necessarily deformed. 

Its particular effects arise from its situation: thus, should an 
exostosis take place in the orbit, the eye would necessarily be 
expelled from that cavity; and an expulsion of the eye from 
that cause has in fact been observed. Should a tumour of this 
nature arise from the clavicle or sternum internally, it might 
occasion death, by compressing the principal blood vessels, ar- 
terial or venous. An exostosis of the pubis might, as already 
mentioned, occasion a retention of urine; or a similar tumour 
on any of the bones of the pelvis, internally, might render 
parturition in the natural way impossible. 

The prognosis differs according to the nature of the primary 
disease from which the exostosis originates, and according to 
the particular change in the texture of the bone. Exostoses 



OF EXOSTOSIS, I79 

from an external cause are much more difficult to cure than 
those arising from an internal one; because the latter may be 
combated by appropriate medicines; but in the former, no in- 
ternal remedy can have any effect, and the extirpation of the 
tumour is the only expedient. An exostosis produced by a scro- 
fulous diathesis is much more difficult to cure than that arising 
from any other constitutional disease. Unfortunately, medicines 
have been as yet found ineffectual in scrofula, and the practi- 
tioner has generally the mortification of seeing exostosis from 
this cause mock his general remedies, and pass on to a caries, 
to which it has a particular tendency. 

The ivory exostosis, if situated so as not to impede the action 
of any organ, is the least dangerous of all ; for although it be 
impossible to procure the absorption of this tumour, in which 
no vessel, nor fibre, nor pore, can be discovered, and which 
appears a compact and homogeneous mass, yet after it has 
gradually acquired a certain volume, which is never very great, 
it becomes stationary, and causes no inconvenience, but that 
arising from its weight. 

Our complete ignorance of the pathology of exostosis, or of 
the manner in which it is formed, accounts for the imperfection 
of our treatment of it. The opinion of J. L. Petit, relative to 
it, is at present totally abandoned: that author attributed the 
greater part of the diseases of the bones to a defect of elasticity 
in the periosteum. We find nothing more probable in the 
opinion of a more modern author, who attributes exostosis to a 
diminution of the natural quantity of phosphoric acid. 

We shall however endeavour to lay down some principles for 
the treatment of it. The first step to be taken, is to discover 
the primary disease, which when once ascertained, must be the 
principal object of treatment. 

If the patient has formerly laboured under a venereal affec- 
tion, which he has reason to think has not been totally eradi- 
cated, or if there are venereal symptoms present, the exostosis 
may be safely attributed to that disease. It may be observed 
here, that a venereal taint which has been but partially com- 
bated, is more difficult to remove than that for which no remedy 
has been used. At all events, mercurial preparations are to be 
judiciously administered, and the use of them persevered in 
until all the venereal symptoms disappear. 

This mode of treatment is certainly the most efficacious; but 
should the evil resist the use of the milder preparations of mer- 
cury, it must be given in small doses, in the state of corrosive 



l8o OF EXOSTOSIS. 

sublimate, which may be advantageously dissolved in a decoc- 
tion of sarsaparilla, or other sudorific article. If mercury in 
any form does not agree with the patient, sudorifies alone must 
be used: three glasses of a strong decoction of sarsaparilla and 
guaiacum, in which a few grains of alcali may be dissolved, are 
to be given daily; and the tumour is to be covered with a 
mercurial plaster. If the pain be very great, and prevent sleep, 
some opium may be added to the plaster. This latter appli- 
cation sometimes affords- very considerable relief. 

When the anti-venereal treatment has been continued for two 
months or more, if the venereal symptoms disappear, and the 
exostoses diminish in size and become indolent, it would be 
useless or even pernicious to persevere in the use of the general 
remedies. It is not unfrequent to find an exostosis which was 
only a symptom of syphilis continue after the removal of the 
general disease, particularly when the infection has existed for 
a length of time in the system. The topical affection should 
in this case be left to nature, if its situation do not impede the 
action of some organ essential to life; under which circum- 
stances, its removal by an operation becomes necessary. 

In treating a venereal exostosis by mercurial remedies, it is 
of the utmost importance to regulate their use in such a man- 
ner as that the mouth may be but slightly affected, and a sali- 
vation avoided. Little reliance can be had on the topical ap- 
plications, with which the tumour is generally covered; nor can 
it be reasonably expected that they should act effectually on the 
osseous system, through the integuments and soft parts. Hem- 
lock plasters, and similar applications, only irritate the skin, and 
occasion erysipelas and excoriations, which add to the suffer- 
ings of the patient. 

The scrofulous exostosis is opposed by the internal use of 
tonic medicines, by the application of discutients to the part, 
by sea-bathing, or by pumping on the part water in which 
some alcali has been dissolved. But often all our endeavours 
are fruitless ; the exostosis degenerates into caries ; the soft 
parts which cover the diseased bone become inflamed, and ab- 
scesses are formed, the openings of which become fistulous. 
The slow fever which ensues from the absorption of the pus 
and the copious discharge, exhaust the patient's strength, and 
the only resource that now remains is amputation; but this 
even is sometimes impracticable, from the situation or extent 
of the diseased part. 



OF EXOSTOSIS. l8l 

When, as is generally the case, the scrofulous exostosis ter- 
minates in caries, the treatment will be the same as if caries had 
supervened without being preceded by exostosis. 

The scorbutic exostosis requires the same treatment as the 
disease of which it is a symptom. As to the cancerous exos- 
tosis, which is as rare as the scorbutic, its cure is as difficult as 
that of cancer itself. When the part cannot be extirpated, 
opiates and other palliative means are to be had recourse to. 

If the disease has originated from an external cause, or if it 
be merely local, the primary disease of which it was a symptom 
being removed, it is best to leave it to nature. The use of 
caustics, or the actual cautery, occasions much pain, and, in- 
stead of doing good, adds to the evil. This is the case with 
an unfortunate woman, who had caustic applied to an exostosis 
of the internal side of the tibia; but which, instead of remo- 
ving the exostosis, produced a necrosis, of which she is not 
yet well, though two years have elapsed since the application 
of the caustic. However, should the tumour, from its situa- 
tion or size, press on, and derange some important organ, as 
the eye for instance, which it may turn to one side or the 
other, or totally expel from the orbit, it will be necessary to 
proceed to the following operation. 

If the tumour rise from one of the broad bones of the skull, 
to which it is connected by a narrow neck, the integuments 
over it are divided by a crucial incision, and dissected from the 
bone. The periosteum is then to be cut round the neck of the 
tumour, which is finally removed by a thin sharp saw. This 
mode of operating is much to be preferred, even when the 
neck of the tumour is not very narrow, to that in which a 
chisel, and mallet of lead, are used; for the concussion given 
to the brain by the latter mode may bring about the worst 
consequences. If the base of the tumour be so thick, that it 
cannot be sawed through by a small fine saw, it will be neces- 
sary to divide it into several parts by vertical sections, which 
parts may be easily sawed through in succession. 

When the chisel and mallet are used, it will be necessary to 
fix immovably the part to be acted on, and to direct the chisel 
obliquely, so that its action by cutting may be increased. If 
after having removed in this manner the greater part of the 
tumour, its base be found carious, it will be necessary to re- 
move by the chisel, or even a scraper, as much as possible of 
the diseased part, and to destroy what remains by the actual 
cautery. 



l82 OF OSTEOSARCOMA. 

If the tumour to be removed by the chisel be very thick, it 
will be necessary to make holes in it in different points by a 
perforating instrument, by which means its basis will be dimi- 
nished, and its removal facilitated. After the tumour has 
been removed, granulations sprout from the surface of the 
bone, and in a little time the wound is cicatrized. But I must 
remark, that cases rarely occur, in which it would be justifia- 
ble to perform this operation, and that in by far the greater 
number of instances the local affection is much less to be 
dreaded than the means used for removing it. 

We have designedly omitted mentioning the lamellated ex- 
ostosis, in which the internal part of the diseased bone is con- 
verted into flesh. This species of disease has been improperly 
confounded with exostosis, but it more properly belongs to 
those classed under the general name of osteo-sarcoma. 



CHAPTER XXII. 



OF OSTEO-SARCOMA. 

WE comprehend under this denomination all the osseous 
tumours to which authors have given the different 
names of spina ventosa, poedarthrocace, and osteo-sarcoma j 
but in collecting them thus under one general name, we do not 
mean to say that these different denominations refer to a single 
disease, but merely that they have, notwithstanding their dif- 
ferences, certain points of resemblance which justify this clas- 
sification. It is extremely difficult, says Marcus Aurelius 
Severin, to ascertain to what kind of organic lesion this affec- 
tion is to be ascribed.* The bone affected is sometimes totally 
converted into a soft, lardy, homogeneous substance, resem- 

* Non est sane facile decerni quo sit genere eensendus hie affeclus. Mar. 
Aur. Sev. de Poedarthrocace, 



OF OSTEO-SARCOMA. 183 

bling a concerous gland. At other times it is filled with fun- 
gous flesh, which is covered exteriorly by a thin plate of com- 
pact substance, perforated by a great number of holes, finally, 
there are eases in which the bone becomes reduced into a soft 
gelatinous substance. We shall give a remarkable example of 
this species at the end of this chapter. 

The first species or variety which we have mentioned is that 
which merits particularly the name of osteo-sarcoma, which 
signifies, in itself, the conversion of an osseous substance into 
flesh: it may be doubted, however, if the name of flesh be 
properly applied to this substance, which resembles rather a 
scirrhus of soft parts than flesh, and which presents no mark 
of organization. The soft parts which surround a bone thus 
affected participate in the disease, which is always announced 
by very acute pains, and which originates sometimes from an 
internal disease, and particularly from the cancerous virus; at 
other times, from an external cause, as a violent contusion: in 
many cases it can be traced to no cause. 

The second species, named spina ventosa, or poedarthrocace, 
consists in a swelling of the head or body of a long bone, in 
such a manner as that its cancelli become very much enlarged. 
The medullary membrane which lines these cancelli becomes 
thick, and granulations sprout from it, which destroy by their 
growth the substance of the bone, so that there only remains 
an external shell filled with small holes. To this species must 
be referred the swellings of the articulations of the phalanges, 
arising from scrofula, and which often lead to the necessity of 
amputating. This operation should not, however, be hastily 
recurred to, as nature sometimes effects a cure in which she 
may be aided by bathing the parts in a diluted solution of pot- 
ash or soap-water. When a bone that has been thus diseased 
is macerated, the internal fleshy substance separates, and the 
dilated bone remains a mere empty and brittle shell. 

In every species of this disease, the pains are at first dull 
and deep-seated, but in a short time they become more in- 
tense, and the volume of the bone increases, though the soft 
parts appear yet in their natural state. The latter, however, 
soon become red and inflamed, and abscesses form in them, 
which burst, and their openings degenerate into fistube. 

The osteo-sarcoma, of whatever species, is in general a dan- 
gerous disease, and often requires the amputation of the part 
affected. When a tendency to this disease from a venereal 
cause is discovered early, its progress may be prevented; but 



1S4 OF OSTEOSARCOMA. 

if the disorganization of the bone has once taken place, its 
structure can never be restored. The swellings of the extre- 
mities of the phalanges of the fingers and toes are the least 
alarming of all affections of this kind. They seldom render 
amputation necessary, in general, the wound in the integu- 
ments puts on a more healthy appearance, the fistulas dry up 
and heal, and the patient recovers, but with the loss it is true, 
of the motion of the joint. 

When the structure of a large portion of bone is disorgan- 
ized by osteo-sarcoma or spina ventosa, and the patient har- 
rassed by acute pain, and exhausted by slow fever, diarrhoea, 
and colliquative sweats, it will be necessary to amputate the 
part, if the operation be practicable. But should the extent 
or situation of the evil render amputation useless or impracti- 
cable, all that can then be done is to support the patient's 
strength by an invigorating diet and tonic medicines, and pal- 
liate his sufferings by means of opium. 

Amputation is generally successful, except in cases of real 
osteo-sarcoma, which, absolutely analogous to a carcinomatous 
affection of the soft parts, takes deep root, and may, like it, 
attack the bone again after this operation has been performed. 
This return is particularly to be apprehended when the lym- 
phatic glands in the neighbourhood of the diseased part are 
swelled and indurated. 

We have spoken of a particular disorganization of the bones, 
in which their substance, and that of the surrounding soft 
parts, become soft, and are converted into a gelatinous mass. 
The following case presents a remarkable instance of this spe- 
cies of osteo-sarcoma. 

A priest, aged forty-seven, fell as he was running in the Rue 
de Barres, the 13th Vendemaire, year 7, and received a con- 
tusion on the right shoulder, which was not, however, so con- 
siderable as to prevent him from attending to his usual occu- 
pations; both pain and contusion vanished in a short time. 
Four months after he felt intermittent pains in the right arm, 
which were relieved by extending the arm forcibly. A tu- 
mour as large as an egg manifested itself near the shoulder, the 
pain arising from which was assuaged by volatile liniment ; but 
it soon became very acute, and the arm lost the power of mo- 
tion. He was received in this state into the Hotel-Dieu, where 
he remained two months, during which time the shoulder was 
kept covered with emollient poultices. The pain diminished, 
but the tumour, which had been stationary, increased rapidly 



OF OSTEO-SARCOMA. 185 

in size, and extended over the shoulder and into the armpit. 
After leaving the Hotel Dieu, he remained with his friends 
until the 2d Ventose, year 9, when he entered the hospital of 
St. Louis. The tumour, or rather the shoulder (for that part, 
though much increased in size, had not lost its natural shape), 
was moveable, though it appeared to be connected by some 
points to the side of the thorax: it was equally hard and elastic 
in every part, but little eminences were formed on its surface. 
The skin, though very much distended, had preserved its na- 
tural colour, and a considerable degree of pressure might be 
made on the tumour without increasing the pain. The right 
trapezius muscle, which supported principally the weight of the 
tumour, was much extended, and drawn into the shape of a 
cord visible through the skin. The pain appeared to be pro- 
duced by the extension of the skin and compression of the aux- 
iliary plexus of nerves : its violence was considerably diminished 
by emollient applications and by the use of opiates, the dose of 
which it was found necessary to augment when the atmosphere 
seemed overcharged with electricity; as the pain was then much 
increased, and seemed to dart in different directions through 
the tumour with the rapidity of lightning. The great extent 
of the swelling of the lateral and superior parts of the thorax, 
our ignorance of its nature, and of the real state of the articula- 
tion, prevented us from amputating at the shoulder joint. 

The tumour continued to augment, and the pains to become 
more intense; the emaciation and debility increased; opium 
could no more procure sleep or diminish pain; diarrhoea came 
on, and the patient died on the 2d Fructidor, five months after 
his entrance into the hospital of St. Louis. The tension of the 
skin of the tumour seemed to diminish, and the tumour itself 
to collapse, on the moment of the patient's death. Its circum- 
ference was still thirty-six inches, and its diameter sixteen: its 
weight, with that of the arm, was about thirty-three pounds, 
while that of the other arm was only about six, which left a 
difference of twenty-nine pounds. When the skin was thus 
relaxed, a fluctuation was perceptible, which could not be felt 
before, unless in the little eminences on the surface, which 
were liable to disappear and change their situation. A trocar 
was twice plunged into the tumour in different parts, yet no 
fluid escaped. I then opened it in presence of Citizen Lassus, 
Thouret, and many other practitioners. 

The skin was thinner than natural, and its texture decom- 
posed: that is, the fibres and lamellx of which it is composed 
94, 



I 86 OF OSTEO-SARCOMA, 

were separated and distinct. The muscles, and particularly the 
deltoides, were extremely emaciated, and seemed to form a 
second fleshy covering not more than one line thick. A yellow 
gelatinous mass was found in the centre, and which resembled, 
in many respects, jelly in which some blood had been mixed. 
The humerus was nearly destroyed to its inferior extremity. 
The nerves and arteries, pressed against the integuments, did 
not seem to have been injured. The surface of the glenoid 
cavity was destroyed, and converted into a gelatinous substance. 
A chemical analysis of this substance proved it to be composed 
of a great proportion of gluten, a small quantity of albumen, 
and some salts. The clavicle was found in a healthy state, and 
no part of the scapula was affected but that which forms the 
glenoid cavity. 

The diseased part has been preserved, and deposited in the 
Anatomical Gallery of the School of Medicine of Paris ; where 
also may be seen a drawing of the tumour in the last stages of 
the disease. An idea of it may be formed from an attentive ex- 
amination of a drawing given by Marc. Aur. Severin* of a 
Spaniard who died of a similar tumour. 

There are other examples of similar tumours. Citizen Las- 
sus has collected the particulars of a great number of cases of 
this kind, and has made them the subject of an Essay presented 
to the School of Medicine. 



* De recondita Abscessium Natura, edit, de Leyd. 



VOLUME II. 



A TREATISE, 



CHAPTER 1. 



OF RICKETS. 



THIS disease is most generally met with in young chil- 
dren, and but very seldom in adults; however, persons 
that have suffered from it in their youth, may be attacked with 
it after puberty. The memorable case given by Morand in the 
Memoirs of the Academy of Sciences, 1753, furnishes a re- 
markable instance of its attack after this period of life. 

The bones of the foetus whilst in the womb may be affected 
by it: Pinel has given, in Fourcroy's Journal, a description of 
the skeleton of a ricketty foetus. But it most generally mani- 
fests itself from the sixth or seventh month, to the fourteenth 
or fifteenth, or much about the period of the first dentition. 
J. L. Petit, and many others, have considered difficult cutting 
of the teeth as a principal cause of it. 

It is not as yet decided whether this disease, the characteris- 
tic mark of which is a softening of the bones from a deficiency 
of phosphate of lime, be a primary affection, or a symptom of 
scrofula, lues, or scurvy: Doctor Portal maintains the latter 
opinion. 



l<jO OF RICKETS. 

We will observe, however, that there seems to be a great 
connexion between rickets and scrofula: the swelling of the 
mesenteric glands, the colour of the skin, the flaccidity of the 
muscles, and other symptoms observed in rickets, are marks 
of a scrofulous diathesis. 

Whatever may be its cause, its progress is as follows: the 
child generally suffers from cutting his teeth, and is tormented 
for some time by a continual diarrhoea; at length the belly 
swells, and becomes hard and tense; the skin is now dry and 
scaly: the limbs diminish in thickness, and the whole body 
becomes emaciated; the ends of the bones swell, and the joints 
of the extremities appear like so many knots; the bones lose 
their consistence, pr become flexible, and the muscular sub- 
stance decays. The patient, reduced to this miserable state, is 
Incapable of moving, and every effort he makes, or even the 
weight of his body, bends the bones. The head preserves, 
however, its natural size, and in most cases becomes even 
larger than natural. The brain, which does not seem to share 
in the general dissolution, becomes evolved, its extension not 
being opposed by the softened bones in which it is included, 
and the understanding is prematurely developed. The eyes 
have an uncommon brilliancy, and all the senses are extremely 
acute: however, cases have been met in which great marks of 
stupidity or dulness accompanied the disease. 

The affection does not always stop here; sometimes the 
bones become carious, or a white swelling appears in some of 
the joints; either of which in general proves fatal. 

The vertebral column is particularly liable to be affected by 
rickets, and the disease is sometimes confined to it alone. 
When the cervical vertebrae are attacked, the anterior part of 
the neck projects, and the head falls backwards, and appears 
sunk between the shoulders. When the affection is general, 
the vertebral column becomes shorter, and is curved in various 
directions; the breast beomes deformed, not only in conse- 
quence of the curvature of the spine, but by the depression of 
the ribs and projection of the sternum; the bones of the pelvis 
fall inwards, and generally the pubis approaches the sacrum; 
and the diameters of the pelvis are so much diminished, that, 
parturition must be rendered difficult or impossible. Howe- 
ver, some women deformed by rickets, bring forth full-grown 
children, without any difficulty; but I believe that in such 
cases the rickets come on after puberty, at which time there is 
much less danger of the pelvis being affected than in infancy. 



OF RICKETS. J9I 

The curvature of the clavicles increases, and becomes more 
prominent anteriorly; the scapulse grow shorter; the humeri 
become curved outward towards their superior part, whilst 
their inferior is carried forwards; the bones of the fore-arms 
are curved in the same manner; but the superior extremities, 
as they do not support any part of the weight of the body, are 
always much less deformed than the inferior, and they are 
always bent towards that side into which the most powerful 
muscles are inserted. 

The bones of the thighs are curved forwards or outwards, the 
anterior and external parts of the thigh becoming more promi- 
nent; the neck of the femur, from being oblique, becomes 
perpendicular with the body of the bone; the knees fall in- 
wards; the internal and anterior sides of the tibia become con- 
vex, and the external side of the legs concave; the feet are 
thrown outwards, not only on account of the knees falling in, 
but also, because the inferior end of the fibula cannot suffici- 
ently oppose the abduction of the foot. 

Nothing certain has been ascertained as to the proximate 
cause of rickets; conjectures however have not been wanting 
on this subject. Some have supposed that the bones are de- 
prived of their phosphate by an acid ; but what acid is this ? 
How is it generated ? Does the acid smell of the breath of the 
ricketty patient indicate any thing respecting it? 

Is the softening of the bones owing to a defect of reparation, 
while their ordinary loss is going on ? or is there a disease in 
the bones by which they are decomposed and consumed, whilst 
the digestive organs do not furnish a sufficient supply of ealca- 
rious phosphate ? or is the passage of this salt from the chylo- 
poetic viscera prevented by the obstruction of the mesenteric 
glands? We must acknowledge that ricketty patients, notwith- 
standing their voracious appetite, appear to digest their food 
but badly, and that the passage of the chyle must be impeded 
by the obstruction of the mesenteric glands, in which calcareous 
concretions have been found; lastly, does the chyle contain a 
less quantity of phosphate of lime than natural? or does this 
salt, instead of being deposited in the bones, pass to other 
parts? and what is the cause of this deviation? 

If the body be anatomically inspected after death, the parts 
will be found in the following state: 

The muscles are pale and emaciated; the cellular substance 
is quite destitute of fat; the brain is in general found larger 
than natural, soft, and containing a preternatural portion of 



1^2 OF RICKETS. 

humidity; the spleen and liver are flaccid and enlarged; the 
intestines are pale, or rather whitish; all the lymphatic glands, 
especially those of the mesentery and bronchia?, are enlarged, 
and the latter sometimes suppurated; the bones, reduced to 
their fibrous state, are flexible, bent in several directions, and 
easily cut. 

There have been various opinions as to the cause of the cur- 
vature of the bones. Glisson, who wrote towards the middle 
of the seventeenth century, is the first who expressly treated 
of rickets: his explanation of the curvature is as follows: 

The humours, says he, that go to nourish the bones, are 
accumulated more on one side than on the other, and thus curve 
the bone, or make it incline to the opposite side, in the same 
manner as a column might be curved by introducing in the 
same line, and on the same side, wedges between its different 
parts. But how is it proved that the humours are deposited 
on one side in preference to another? and how comes it that 
the curvature takes place in most persons in the same direc- 
tion ? 

Mayow, an English author, gives the following hypothesis: 
the tendons being dry and shortened, oppose the elongation 
of the bones, and bend them in the same way as a young tree 
is bent, by bringing both its ends towards one another by 
means of a cord. But, without having recourse to this far- 
fetched comparison, we find an easy and natural explanation 
of the fact in the effects of the weight of the body, and mus- 
cular contraction. The deviations are in general an excess of 
the natural curvature; and it is easy to conceive that the weight 
of the body, and muscular action, which produce this natural 
curvature, may occasion an excess of it, when the bones are 
incapable of resisting the forces that act on them. It is also 
found that the natural as well as the diseased curvature is al- 
ways in the direction in which the most powerful muscles act; 
thus the tibia and fibula are curved outwards and backwards; 
and the femur is curved inwards and backwards, the muscles 
of the internal and posterior part of the thigh being more 
powerful than those of the external and anterior. 

Rickets is an hereditary disease in some families, though 
parents that have been affected with it, have sometimes a 
healthy and robust offspring. I think it can be traced, in 
some instances, to a venereal taint, which, though not the 
immediate cause, is very often an exciting cause of it and scro- 
fula. At least, it is certain that syphilis transmitted from pa- 



OF RICKETS. I93 

rents to their children, appears in the latter in a manner very 
different from that in which the former are affected. Thus 
we find, that the children of the indigent and profligate are 
those most generally affected with rickets; but at the same 
time it must be allowed, that there are many circumstances 
which conduce to this disease 5 such as a damp and cold resi- 
dence, impure air, inattention to cleanliness, and a deficiency 
of food. 

Though we do not fully adopt the opinion of Petit as to the 
influence of dentition, still we must allow that the action then 
going on in the osseous system, must be intimately connected 
with the cutting of the teeth; and that difficult dentition, the 
pain and bowel complaints arising from it, may favour, in a 
powerful manner, the action of the exciting causes of rickets. 

It is singular enough that the teeth preserve their hardness, 
though they become loose from the softening of the alveolar 
processes: the softening of the jaw bones is sometimes attended 
with excessive pain, but at other times it takes place without 
any pain at all. 

The prognosis is always unfavourable in rickets; there is no 
medicine which acts directly against it: and even in the most 
favourable cases it is impossible to guard against deformity. 
However, the danger to life is great in proportion to the num- 
ber of bones affected, the more or less speedy progress of the 
disease, and the age of the patient. Children at the breast are 
in greater danger than those that have reached three or four 
years. If the bones about the thorax be considerably affected, 
the cavity is diminished, the lungs are compressed, the func- 
tion of respiration goes on imperfectly, and hence a number of 
diseases which are fatal of themselves. 

Sometimes the disease advances but slowly, and the patient 
arrives at puberty before he is quite well; but the great revo- 
lution that takes place in his system at this time, arrests the 
progress of the complaint. Measles, small-pox, and other 
diseases to which children are subject, have sometimes brought 
about this happy termination: the limbs recovered their size, 
the enlargement of the joints disappeared, and no mark of 
rickets remained but the deformity. 

We know of no medicine which can be said to possess any 
efficacy in this disease : tonics are indicated, and they should 
be used. But the principal advantage is to be derived from 
general treatment: the patient, if resident in a city, is to be 
removed to the countrv, where an elevated and dry situation 
25 



194 OF RICKETS. 

should be chosen; he is to be supplied with a nourishing diet, 
and a moderate quantity of wine. But as the poor, amon^ 
whom the disease is most frequently observed, cannot change 
their residence, they should be placed in the highest apartment 
of the house, which should be kept well ventilated; and in the 
warm season the patient covered with a shirt, should be exposed 
for a considerable time every day to the sun; care, however, 
should be taken that his head be protected against the influence 
of the rays. 

The bed on which ricketty patients lie, should consist of no- 
thing more than a hair mattress, or oaten chaff; or it might 
be made of dried fern-leaves, among which some aromatic 
herbs were mixed. Such beds are much better than those 
made of feathers; for they do not yield to the weight of the 
body, and they are much drier. If the patient be very young, 
he should be placed on his back, so that the weight of his 
body may have as little influence as possible on the bones; but 
as it is painful to remain constantly in this position, he may be 
allowed to sit up now and then, but not on a soft chair: he is 
to be placed on a seat capable of making a uniform resistance, 
with a high straight back, and without arms. If the seat were 
soft, the patient, to find a. point d'appni^ would incline forwards; 
and if it had arms, were he to lean on them, his shoulders 
would be raised, and the cervical vertebrse curved forwards. 
He should not be allowed to walk for a considerable time; for 
at first he will be incapable of doing so without assistance, and 
the strings and ribbands necessary for supporting him, contri- 
bute, by pressing on the parietes of the thorax, to deform that 
cavity. 

Frictions are useful. They may be made either with dry 
flannel, impregnated with aromatic vapours, or with flannel wet 
with mint, rosemary, lavender, or other aromatic waters. A 
hair brush, much used by the English, is an excellent instru- 
ment for this purpose. Frictions determine the fluids to the 
surface of the body, promote perspiration, and increase the 
circulation. 

The clothing should be wide, and composed of materials 
which are light, and which do not transmit freely the heat of 
the body. If the patient be a child at the breast, the nurse's 
qualities should be inquired into; if she is feeble, unhealthy, 
or pregnant, the child should' be committed to another nurse, 
possessing the very opposite qualities. If the child be weaned, 
he is to be nourished with well-fermented bread, and animal 



OF RICKETS. 195 

food simply roasted ; and wine is to be allowed him in small 
quantities, often repeated. As to exercise, if it do not in- 
crease the curvature of the bones, as much of it should be taken 
as will not fatigue the patient; and when the softness of the 
bones is such that any exercise which would require conside- 
rable muscular action cannot be used, riding in a carriage, 
or sailing, should be had recourse to. 

Independently of the general means just pointed out, there 
are particular remedies which may be used in cases to which 
they are adapted. 

If the patient suffer from dentition, that is, if he be tor- 
mented with griping pains and diarrhoea, or if he shriek se- 
verely now and then, and have convulsive twitches, opium 
should be given. If he be troubled with worms, rhubarb and 
other supposed vermifuge medicines may be administered. 

It is very common to find ricketty patients troubled with 
worms: the weakness of the alimentary canal, and the quan- 
tity of mucus collected in it, favour the generation of worms, 
the existence of which in the intestines is indicated by colie 
pains, itching of the nose, acidity of the breath and perspira- 
tion, dilation of the pupil, &c. &c. 

We may endeavour to discuss the swelling of the mesenteric 
glands, by small doses of infusion of rhubarb, and by repeated 
frictions on the abdomen. I am confident that much benefit 
might be derived in these cases from making the patient laugh 
heartily every day, by tickling him : in this convulsive motion, 
the organs contained in the cavities of the thorax and abdomen 
are agitated and pressed in every direction, and the motion of 
the fluids in their small vessels is accelerated. 

If it appear that syphilis or scrofula has had any share in 
producing the rickets, the treatment applicable to each of these 
diseases should be had recourse to. In case of a venereal taint 
being the cause, tonics should be combined with the use of 
mercurials; for the latter, by inducing debility, accelerate the 
progress of the rickets. 

The knowledge of the cause of the softening of the bones, 
necessarily leads to endeavours to obviate it, or repair the in- 
juries it occasions. But how are we to introduce a sufficiency 
of phosphate of lime? How are we to stimulate the absorbents, 
and make them take up a greater portion of this salt? And, 
supposing that this could be effected, how can we cause it to be 
deposited in the bones? Madder, from its known property of 
tinging the bones red, was supposed to have a particular action 



1$6 OF RICKETS. 

on the osseous system, but it is now well ascertained that it 
has no greater effect in rickets than any other bitter plant. 

Thus it appears that our chief object in treating this disease, 
is to restore general health and strength as much as in our 
power: the general treatment already pointed out, is what is 
most to be depended on for this purpose, but it may be assisted 
by the use of bark and other tonic medicines. 

Mechanical means have been proposed for obviating the ef- 
fects of this disease. It is nearly useless to attempt using any 
machines with very young children, and it is also- impossible 
to confine them on their back in bed; besides, it would be 
extremely injurious to keep them confined in this posture: the 
continued extension of tile limbs, and the inactivity of the 
muscles, would add to the general debility, and consequently 
increase the disease. Splints, then, applied to the limbs, strong 
leather boots, and the apparatus for the spine 3 are really useful 
only in cases in which the patient is of a certain age, and when 
the progress of the disease is gradual, and the strength not too 
much exhausted; and even in most of these cases, the inac- 
tivity necessarily occasioned by these machines, is productive 
of disadvantages which are not compensated by their good 
effects. Apparatus of this kind are fitter for correcting vicious 
attitudes contracted by healthy children, than deformity arising 
from rickets. 



197 



CHAPTER II. 



OF THE FRAGILITY OF BONES. 

WE have seen that a softening of the bones may be pro- 
duced by a deficiency of phosphate of lime: we shall 
now consider a disease of an opposite character, which con- 
sists in a deficiency of the gelatinous part. This substance, to 
which bones owe their flexibility, and in which their vitality 
resides, may be so deficient in them, that they will break on 
the application of very slight causes. This disease has been 
called friability, or fragility, from the tendency of the bone to 
crumble or fall in pieces. The state of the bone, in this case, 
may be well conceived from that of a calcined bone. 

This affection is a natural consequence of old age. The pro- 
portion of phosphate of lime deposited in the osseous tissue, 
increases as we advance in life, and that of the organized part 
diminishes in a similar proportion*, so that a period arrives at 
which the quantity of the former so much predominates, that 
the bones, dead as it were before life abandons the other parts, 
break on the slightest occasions. 

The disease at this period of life is necessarily incurable. If 
the fractures be reduced, and an apparatus kept applied on the 
limb for several months, no progress towards consolidation is 
observed. Tonics and stimulants are of no use. There are so 
few vessels in the bones capable of conveying fluids, that no 
granulation form. 

A similar fragility of the bones is observed in adults; but in 
them it arises from a venereal, scrofulous, or cancerous taint. 

When the whole mass of fluids is infected with the matter 
of cancer, it sometimes happens that this virus attacks the 
bones, destroys their vital parts, and renders them as brittle 
as if they had been calcined. Saviard and .Louis mention cases 
of this kind. The latter relates the case of a nun who attended 
La Salpetriere, who broke her arm by simply leaning on a ser- 
vant as she was entering a carriage. A very singular case of 
this kind is related in the London Medical Journal; this un- 



198 OF THE FRAGILITY OF BONES. 

fortunate person could not turn in bed without fracturing some 
bone. 

This alarming symptom is completely irremediable when it 
arrives at this stage. 

The bones are sometimes remarkably brittle in the latter 
stages of syphilis. In such cases the primary disease claims 
our chief attention. 

The bones in the latter stages of scurvy become so brittle, 
that they break on slight occasions, and do not consolidate af- 
terwards. Mead observed, that scurvy was verv unfavourable 
to the consolidation of fractures, and that in some cases of 
sailors which he observed, the callus was destroyed by scurvy 
after it had been formed. 

If the bones of a scorbutic person be boiled, the periosteum 
separates very soon, lamellae scale off, and, in some cases, the 
bone dissolves entirely. They also fall into powder if kept for 
some time, but particularly if exposed alternately to heat and 
moisture. 

We may conclude from the preceding observations, that 
fragility is rather a symptom of senility, or of some disease that 
affe&s the bones, by destroying their organic parts, than a pri- 
mary disease. We should not have consigned a chapter to it, 
did we not hope, that the etiology of rickets may in time be 
elucidated by a comparison of these two affections. 



199 



CHAPTER III, 



OF SPRAINS. 



SPRAIN may be defined, a more or less violent tension of 
the ligaments and other soft parts surrounding an articu- 
lation; the tension may be carried so far as to burst and lacerate 
many of the ligaments. All the articulations are not equally 
liable to this accident; those which admit of an extensive and 
free motion, all the round or loose articulations, in which the 
bone moves in a variety of directions, as the articulation of the 
os humeri with the' scapula, and that of the femur with the 
ossa innominata, are very little subject to it. The latitude of 
motion they admit of, the small number, laxity, and parti- 
cular structure of their ligaments, render them more liable to 
luxations from inconsiderable efforts, than to sprains. In the 
articulations by ginglymus, on the contrary, in which the mo- 
tion is confined to two ways by the reciprocal conformation of 
the surfaces of the joint, and by strong and numerous liga- 
ments, sprains take place oftener than luxations. Of this 
kind of articulation is that of the foot with the leg, in which 
the astragalus, received like a tenon into a quadrangular cavity, 
is surrounded on all sides by very strong ligaments. Next to 
the articulation of the foot comes that of the wrist, then those 
of the knee and elbow, in which a sprain rarely occurs. 

The nature of the affection may be thus explained : suppose 
the foot or hand to be fixed, and the leg or fore-arm pushed 
forwards in any direction, the ligaments placed on the side 
against which these parts are forcibly propelled, will be put in 
a considerable state of tension, and strained; the tension may 
be carried so far as to lacerate the ligaments, of which there 
have been many instances. The tendons, and other soft parts, 
such as the nerves, vessels, and even the skin, are overstretched 
and pained. Those parts placed on the side towards which 
the displaced bone tends, are more or less injured in the angle 
which intercepts the luxated bones; they experience a contusion, 



200 OF SPRAINS. 

by which the small vessels are bruised and lacerated, and a con- 
siderable ecchymosis produced. The tension to which the 
parts of the joints are subjected in sprains, is not then confined 
to the ligaments alone, it extends to all the parts in the neigh- 
bourhood ; this gives an explanation of the sharp pains that 
accompany them, and of the inflammatory swelling which 
succeeds. In fact, although ligaments are endowed with a 
peculiar kind of sensibility, which renders the extension of 
them painful, nevertheless, they do not possess a sensibility so 
exquisite as that the irritation of them alone could cause so 
much pain, and such a considerable inflammatory determina- 
tion, as that frequently occasioned by a sprain. 

A sprain, then, in the moment of its production or taking 
place, consists only of the tension, and sometimes laceration 
of the soft parts surrounding an articulation-, but the pain 
which arises from it, quickly determines the fluids to the irri- 
tated part; a swelling more or less considerable supervenes; 
the skin often appears black, livid, and spotted, from the in-* 
filtration of the blood which escapes from the ruptured vessels 
into the cellular texture. 

When both parts of the affected articulation are formed of 
many bones, it may happen that the ligaments which unite 
them may be torn, and the extremities of the articulations 
disjointed and separated from one another. This diastasis has 
been observed in the inferior extremities of the tibia and fibula, 
in those of the radius and ulna. 

When the sprain is slight, the pain produced by it gradually 
diminishes, the swelling is resolved, the ecchymosis extends 
and disappears, the motion of the parts becomes easy, and at 
the end of some days the articulation is restored to its natural 
state. Nevertheless, if the sprain has been considerable, and 
especially if very strong ligaments, such as the internal liga- 
ments of the articulation of the foot with the leg, have been 
partially or entirely torn, nature requires a considerable time 
to unite the divided part; the joint with difficulty acquires 
strength, and a feebleness remains in it, which disposes it to 
the same accident. 

A sprain is easily distinguished by attending to the history 
of the circumstances relating to it, such as a fall or false step, 
in which the foot or wrist, as the vulgar say, has been more 
or less wrenched. The state of the articulation that has suf- 
fered, ought however to be attentively examined, in order to 
discover if the ligaments have been lacerated, or if a disloca- 



OF SPRAINS. 201 

tion of the extremities of the joint be combined with the sprain. 
When the parts admit of motion in every direction, however 
difficult and painful it may be, we conclude that a simple 
sprain, and not luxation, has taken place. 

The prognosis is unfavourable, in proportion as the extension 
and laceration have been considerable. In scrofulous persons 
sprains are very dangerous, because they often give rise to 
white swellings. 

The treatment of sprains varies according to the continuance 
of the affection. Should the surgeon be called in on the mo- 
ment that the sprain has taken place, he should endeavour to 
prevent the effects of the irritation caused in the strained joint. 
For this purpose the diseased part is to be plunged into cold 
water, or still better into powdered ice. The brisk impression 
occasioned by the cold, constricts all the parts, and diminishes 
the diameter of all the small vessels, so much, as to prevent 
the admission of the blood determined to them by the irrita- 
tion. Besides, the extreme cold, by diminishing sensibility, 
abates the irritation itself, and thus in two ways prevents the 
influx of fluids. But to derive from refrigerants all the advan- 
tages that may be expected, it is not enough to leave the dis- 
eased part exposed to them for half an hour, or even an hour^ 
it must remain immersed in them during several hours, and 
they must be renewed as they acquire heat, so that their action, 
at once repellant and sedative, may preserve the same energy. 
These means, if not continued for a certain length of time, far 
from being useful, do an injury, by exciting a reaction which 
determines the humours to the part where the irritation had 
already too powerfully invited them. Should a woman have 
her menses when this accident happens, these means could not 
be had recourse to 5 the immersion in cold water would almost 
infallibly suppress the menstrual discharge 3 and induce a disease 
more grievous than the sprain itself. The same would be the 
case should we have to treat a person with delicate lungs. 
"When the part is removed from the ice, it must be covered 
with cloths soaked in cold liquids, such as vegeto-mineral. 
water, spirit in which camphor or sal ammoniac has been dis- 
solved, a mixture of vinegar and water, &c. with which the 
part is to be continually moistened. By a treatment of this, 
kind, a violent sprain often produces only a very moderate 
swelling, and the disagreeable consequences are never com- 
pletely developed. 

26 



202 OF SPRAINS. 

It is scarcely necessary to condemn here the absurd practice 
of ignorant bone-setters, who agitate, twist, and press the 
affected joint in every direction, or advise the patient to roll a 
cylinder of wood under the sole of the diseased foot. The 
repellent mode of treatment can be successful only shortly after 
the accident has taken place; at the end cf twelve hours, the 
irritation which has not been subdued, and the effects of which 
have not been prevented, has already produced an influx of 
humours, with swelling, pain, and inflammatory tension of the 
adjacent parts. It then becomes necessary to take a quantity 
of blood proportioned to the age and temperament of the pa- 
tient, the degree of the sprain, and severity of the symptoms. 

Emollient cataplasms are applied, with the view of relaxing 
the solids, and of abating irritation; the use of them is to be 
continued as long as the inflammatory tension and pain are pre- 
sent; but when the swelling begins to be resolved, which 
change is announced by the subsiding of the tumour, the 
wrinkling of the skin, the extension of the ecchymosis over 
the limb, which becomes yellow, resolvents are to be combined 
with the emollients: for this purpose a poultice composed of 
crumbs of bread and linseed meal boiled in wine, or in a strong 
decoction of elder-flowers, is applied; the cataplasms are to be 
rendered more and more resolvent, and towards the end of 
the complaint, resolvents only are to be used: lastly, solvents, 
such as styr ax-plaster, sprinkled over with the flower of sulphur, 
&c. &c. are to be substituted for them, and pumpings with 
water in which some sulphuret of potash has been dissolved, 
or with natural or artificial warm waters, are to be prescribed. 

The diseased part must be kept in a total state of inaction 
for as long time as possible, and the limb preserved in the ho- 
rizontal posture, which favours the subsiding of the tumour, 
by facilitating the return of the fluids. The patient should not 
be allowed to walk, or make use of his wrist,' until the pain 
has entirely vanished; he should even be" informed that the 
pains will return, and be felt at intervals for six months or a 
year, and also advised not to fatigue too much the weak joint. 
A roller is to be firmly passed round the foot and leg: by this 
precaution the oedematcus swelling of the limb will be pre- 
vented, which, without it, would inevitably take place. This 
treatment is indispensably necessary, when the sprain is accom- 
panied with a complete or incomplete rupture of some liga- 
ment, and with the separation or diastasis of the ends of the 



OF SPRAINS. 203 

joint, a complication which renders the cases more serious, and 
the cure more tedious and difficult. 

If the sprain be badly treated, or if the patient use the af- 
fected joint before all the symptoms entirely disappear, some 
swelling still remains in the part; soon, in consequence of 
some stress, the pains that were only lulled, re-appear, the 
swelling increases, but in a slow manner, and assumes the ap- 
pearance rather of an indolent than inflammatory tumour, 
being very hard and without any change of colour in the skin; 
and in time it extends to all the ligaments and soft parts in the 
neighbourhood of the joint. The healthiest and most robust 
persons may have tumours of this kind supervene, as the conse- 
quence of ill-treated sprains. Nevertheless it is certain, that 
the existence of a scrofulous diathesis gives a strong predisposi- 
tion to them: in this latter case, the sprain may be considered 
the exciting cause of the disease, which attacks an enfeebled 
and pained part predisposed to it. However, sprains that have 
been neglected, often render amputation necessary, on account 
of the enlargement and caries of the bones that succeed to 
them. 

It may suffice for us to say, without giving the particulars 
of numerous instances of this melancholy termination, that 
sprain, an affection so trifling in the eyes of the vulgar, is one 
of the most frequent causes of diseases of the joints, which, in 
civil hospitals, render amputation necessary. 

The rules to be followed in the treatment of the bad symp- 
toms succeeding to sprains, will be given in the chapter on 
white swellings. To give them here, would put us under the 
necessity of making useless repetitions. 



•204 I 



CHAPTER IV. 



OF LUXATIONS IN GENERAL. 



LUXATION takes place every time that the articular ex- 
tremities of bones abandon their natural relations, whe- 
ther it be that the head of a bone escapes from a cavity destined 
to receive it, or that the surfaces of the joint cease to corres- 
pond one to the other. The dislocation may be either total or 
partial: hence luxations are divided into complete and incom- 
plete. 

In order to consider the nature of luxations, a previous know- 
ledge of the anatomy of the articulations, and of the different 
modes of the junction of bones, is necessary. Thus, to form a 
just idea of the different kinds of luxation of which the bone is 
susceptible, of the manner in which it takes place, to under- 
stand perfectly its symptoms, easily seize the indications of 
cure, and make choice of the proper means of fulfilling them, 
the particular conformation, and mutual or reciprocal relation 
of the surfaces by which the bones come in contact, and are 
articulated, must be previously known. These relations should 
be learnt on fresh bones covered with their cartilages, and 
having their cavities furnished with the cartilaginous borders 
which increase their depth, and with the synovial glands which 
furnish the liquor by which they are moistened. 

It is equally necessary to have correct notions of the muscles 
surrounding the articulation; of the vessels and nerves in its 
vicinity; of the motions of which the joint is capable, and the 
changes which the soft parts and bony prominences undergo 
when these movements are executed. 

After having acquired this information, it is necessary to 
know that luxations, as well as fractures, present characters 
which are general and common to all luxations, and objects 
which are peculiar and confined to each species. 



OF THE DIFFERENCES OF LUXATIONS. 205 



SECTION I. 



Of the Differences of Luxations. 

Luxations, taken in a general point of view, differ from 
one another-, 1, with respect to the articulation in which they 
take place; 2, the extent of the dislocation; 3, the direction in 
which the bone is displaced; 4, the length of time they have 
continued ; 5, the circumstances which accompany them, and 
which mark them out as simple or compound; 6, and lastly, 
with respect to the cause that has produced them. 

The extent and variety of motion a joint admits of, give the 
measure of the tendency of the bones composing it to be lux- 
ated. Thus, the round or loose articulations, such as that of 
the humerus with the scapula, are those in which luxations are 
most frequent; in the ginglymoidal articulations, on the con- 
trary, which admit only of motion in two opposite directions, 
they are very rare. The frequency of luxations in the orbicular 
articulations, and the unfrequency of them in the ginglymoidal, 
may be explained from many circumstances independent of 
the greater or less motion they admit of. In the ginglymoidal, 
the surfaces of the extremities of the bones which come in 
contact, and are adapted to one another, are of considerable 
extent; and when a foreign power acts on them, and forces 
them in contrary directions, they have to describe a great space 
before dislocation takes place; the ligaments which surround 
them are very numerous and strong, and the muscles placed 
on their sides are disposed in a manner to prevent their de- 
rangement. 

With respect to the extent of the dislocation, luxations are 
distinguished into complete and incomplete: the latter denomi- 
nation is given them when the surfaces of the joint are yet in 
contact by some points of its cartilages, without being entirely 
displaced, but at the same time not exactly corresponding. In- 
complete luxations take place only in the articulations by gin- 
glymus, as in those of the foot, the knee and the elbow. When 
complete dislocation takes place in these parts, the force that 
has effected it must have been very great; thus luxation in 
them is almost always incomplete. The same is not the case 



206 OF THE DIFFERENCES OF LUXATIONS. 

with the orbicular articulations, the greater number of which 
are susceptible of no other luxation than the complete. 

If the head of the humerus or femur is forced on the cartila- 
ginous brim that surrounds and deepens the cavity destined to 
receive it, the osseous ball, covered with cartilage, and having 
its surface smooth and lubricated, comes in contact with the 
parts on which it rests by only a very few points, and thus 
either re-enters the cavity it has abandoned, or escapes entirely 
out of it: in the latter case the luxation is complete. 

There are some articulations, which, though truly orbicular, 
may nevertheless admit of incomplete luxations. For instance, 
the head of the astragalus may be so displaced as only to aban- 
don in a partial manner the cavity in the posterior face of the 
os naviculare; but in this case the orbicular ligament is tight, 
very strong, and the motion inconsiderable. In considering 
fractures in general, we have seen that they could not, like 
luxations, be distinguished into complete and incomplete, the 
latter denomination not being adapted to a solution of conti- 
nuity in one of the bones of the leg and fore-arm. We shall 
see, in treating of luxations of the lower jaw, that some, on a 
principal somewhat similar, but equally erroneous, have wished 
to call incomplete that in which only one of the processes of 
the maxilla is displaced from the glenoid cavity of the os tem- 
poris. Lastly, to conclude what relates to the extent of the 
dislocation, when the head of the bone has entirely escaped 
from its cavity, it may still be forced to a greater or less dis- 
tance between the interstices of the muscles. 

As to the different directions in which a bone may be dis- 
placed: in the round articulations it may be luxated in the di- 
rection of all the radii that pass from the centre of the circle 
formed by the circumference of the articular cavity. There is 
not, in fact, a point of the edge of the glenoid cavity, by which 
the humerus may not escape. Nevertheless, as shall be ex- 
plained when we treat of particular luxations, various circum- 
stances depending on conformation cause the luxation to take 
place in certain directions ascertained by observation, so that 
the varieties of luxations distinguished by the course of the 
displaced bone are much less numerous than might at first be 
supposed. Luxations are named, superior, inferior, anterior, 
posterior, &c. according to the approximation of the bone to 
these directions. With respect to the ginglymoidal articula- 
tions, which, as we have seen, constitute a class entirely diffe- 
rent from the orbicular, considered in what relates to their 



OF THE CAUSES OF LUXATIONS. 207 

luxations as well as their motions, the bones which form them 
describe two lines, during their luxation, which cross one 
another at right angles; the first by passing from one side to 
the other, the second from the anterior to the posterior part. 

The continuance of luxations constitutes a difference of the 
highest importance, and influences considerably the manner of 
treating them. In fact, the reduction of a luxated bone which 
has remained so for several days, is much more difficult than 
that of one more recently displaced. 

The soft parts, and the bone itself, have acquired a certain 
position, and the ligaments and muscles surrounding the dis- 
eased joint become stiff, and difficultly yield to the efforts made 
to reduce the bone. If a certain number of days have elapsed 3 
the laceration in the ligaments may be so far cicatrized as to 
render the reduction impossible. Lastly, the extremities of 
the joint may be grown to the bones against which they have 
been forced. 

A luxation may be simple, that is to say, consist only of 
the reciprocal abandoning of the surfaces of the joint, and the 
laceration of the ligaments which is inseparable from it : it may 
be complicated with greater or less contusion, with a wound, 
fracture, or rupture of a blood-vessel, and consequently an ef- 
fusion of blood into the cellular substance, with contusion of a 
considerable nerve, and a paralysis of the organs to which it is 
distributed, &c. &c. 



SECTION II. 



Of the Causes of Luxations. 

The causes maybe divided into external and internal: both 
are predisposing or occasional. 

The predisposition to luxation may depend on circumstances 
natural or accidental. The natural are, the joint admitting of 
great latitude of motion, the small extent of surfaces by which 
the bones come in contact, the laxity and small number of the 
ligaments uniting them, the weakness of one side of an articu- 
lation, arising, for instance, from a great notch on one side, 
as is observed in the interior and inferior part of the acetabulum. 
Disease, such as a paralysis of the muscles which surround an 



208 OF THE CAUSES OF LUXATIONS. 

articulation, a debility and relaxation of its ligaments, give also 
a predisposition In a paralysis of the deltoid muscle, the 
weight of the arm alone has been known to occasion an elon- 
gation and gradual relaxation of the round ligament of the ar- 
ticulation of the humerus with the scapula, and remove the 
head of the former bone to the distance of two or three inches 
from the glenoid cavity. I have observed in a child, who la- 
boured under an atrophia of the muscles of the arm an empty 
space of nearly an inch between the head of the bone and the 
surface of the cavity, which could be distinctly felt through the 
emaciated deltoid muscle. 

Sometimes the relaxation of the ligaments appears without 
any evident cause, and gives such a disposition to luxations, 
that they take place from the slightest causes: such was the 
case of a woman, who could not yawn even moderately with- 
out luxating the lower jaw. It may not be amiss to observe, 
that these luxations, depending on the excessive relaxation of 
the ligaments, are, on account of the relaxation itself, very 
easily reduced. 

A swelling or distension of the cartilages of the joints and 
caries of the bones, may also dispose to luxations; but in these 
cases, the affection of the cartilages and the caries constitute a 
particular and primary disease. Luxation is to be considered 
then only as an additional symptom ; and it is perhaps without 
foundation, as shall be mentioned in the chapter on spontane- 
ous luxations of the femur, that authors have ranked this dis- 
ease of the hip among these affections. 

In order that external violence, a blow, a fall, or even the 
action of the muscles, produce luxation in a round articulation, 
the axis of the bone must be placed in a direction more or less 
oblique with respect to the surface with which it is articulated. 
If, for example, the os humeri hang exactly along the sides of 
the body, or perpendicularly with respect to the glenoid cavity 
of the scapula, no force is capable of luxating it. If a person 
fall on the elbow while the fore-arm is in this position, the 
head of the humerus will be forced against the cavity formed 
to receive it; but if the arm be removed from the body, the 
axis of the os humeri will fall obliquely on the surface of the 
glenoid cavity, which will favour its passing out of the socket; 
and this disposition to luxate will be increased in proportion as 
the angle formed by the axis of the bone with the surface of the 
cavity deviates from a right angle. 



OF THE SYMPTOMS OF LUXATION. 200, 

A fall, or any other kind of external violence, may cause a 
luxation almost always incomplete in the ginglymoidai articula- 
tions} but in the round articulations, the action of the muscles 
has constantly a share. Thus, for instance, if a person fall on 
the elbow whilst the arm is raised from the body and carried 
directly outwards, the shock which this part receives will cer- 
tainly tend very much to force the head of the humerus out of 
its cavity on the lower and internal side; but the action of the 
pectoralis major, latissimus dorsi, and teres major, contributes 
very much to it. In fact, the elbow, resting on the ground, 
becomes the fulcrum, or centre of motion of the humerus*, in. 
this state we obey a mechanical instinct, which leads us sud- 
denly to bring the arm close to the body; and as the resistance 
made by the ground prevents this, the violent and instantane- 
ous contraction of the pectoralis major, latissimus dorsi, and 
teres major, draws downwards and inwards the head of the 
humerus, the luxation of which is, as we have demonstrated, 
the effect of two causes. 

In this instance, we have seen how muscular action conduces 
to luxations in the round articulations; in some cases, this ac- 
tion alone is sufficient to effect them. It is in this way that 
violent convulsions produce luxations as well as fractures. 

Whatever may be the manner in which the causes act, lux- 
ations are always accompanied with more or less laceration of 
the ligaments surrounding the joint; and in the round articu- 
lations, as those of the shoulder and hip, the fibrous capsules 
are always torn,, 









SECTION III. 



Of the Symptoms of Luxation, 



We will not mention pain and inability of moving the limb, 
as they are equivocal symptoms, and common to luxations, 
fractures, and simple contusion. They are not, however, to 
fee entirely overlooked; but when we make a diagnosis, we 
should endeavour to found it on the existence of symptoms 
manifest to the senses, such as an elongation or shortening of 
the limb, a change in its shape and direction, and lastly, the 
absolute impossibility of performing certain motions. We will 



2IO OF THE SYMPTOMS OF LUXATION. 

say little on the manner of ascertaining the existence of these 
different symptoms, as we have already spoken of it in giving 
the general history of fractures. 

A luxation cannot possibly exist without the affected limb 
being either lengthened, as happens in the inferior extremity, 
when the head of the femur passes out downwards and inwards, 
and rests in the foramen ovale, or shortened, as takes place 
when the same bone is luxated upwards and backwards, and 
has its superior extremity directed towards the external depres- 
sion in the ilium. In truth, the shortening or elongation is 
rarely observed but in the orbicular articulations; however, the 
absence of these symptoms in the ginglymoidal is amply com- 
pensated by the superficial situation of the bones, which ren- 
ders it easy to ascertain their relative positions. 

The direction of the bone is changed; for the luxated end 
cannot leave its natural place without having the other carried 
in a direction contrary to it. Thus, in the luxation of the hu- 
merus downwards and inwards, the arm is placed obliquely 
downwards and outwards, instead of falling straight along the 
side. This symptom, taken from the direction of the member, 
is, like many others, much easier to be distinguished in recent 
luxations than in those that have continued for a considerable 
time. From the change of situation and direction of the bone, 
there must necessarily result a relaxation of some muscles, 
whilst others are considerably overstretched and strained, as 
may be seen with respect to the deltoid muscle in cases of lux- 
ations of the humerus, which are the most frequent. This 
unequal and unnatural tension and relaxation of the muscles may 
contribute also in aiding us to form a diagnosis in cases of lux- 
ation. 

The change in the shape of the limb is also removed by time. 
In fact, one would presume, from the manner in which the 
shape of the point of the shoulder is restored after a luxation of 
the humerus by a projection of bone arising from the convex 
edge of the acromion, that the head of the os humeri was not 
forced into the axilla. In these alterations of the natural shape 
of the limbs, we are to comprehend the changed relations of 
the eminences of a joint to one another, the existence of pro- 
jections in places where the limb should present depressions, 
and depressions where it should present eminences. In the 
luxation of the arm inwards and downwards, a hard tumour is 
felt in the axilla, which, on account of its roundness, is easily 
ascertained to be this part of the bone. 



OF THE PROGNOSIS IN LUXATIONS. 211 

Our limbs, even when fractured, may be made to perform 
several motions, and be put in various attitudes. In a fracture 
of the femur, the surgeon, not in truth without causing more 
or less pain to the patient, may, by taking hold of the leg, 
move it round in a circular direction, and may point the foot 
inwards and outwards — motions altogether impossible in luxa- 
tions, before the reduction of the displaced bone. 

By combining all these symptoms, it is impossible to form a 
wrong diagnosis in cases of luxation. A mistake would be ex- 
tremely dangerous; for if the luxation be not discovered, the 
patient attributes his not being able to use his limb to the con- 
tusion and pain; but if the continuance of the symptoms in- 
duce him to have recourse to other persons better instructed or 
more attentive, they ascertain the nature of the affection, to 
the no small shame of the surgeon who has mistaken it. In- 
stances of errors of this kind are more frequent than one would 
imagine, especially in the country, where the branch of surgery 
which we treat of in this work is often in the hands of ignorant 
persons. 



SECTION IV. 



Of the Prognosis in Luxations. 

The luxations which take place in the ginglymoidal articu- 
lations, differ much from those in round articulations, in what 
relates to prognosis, as well as in many other points of view: 
the latter are much less dangerous than the former. As the 
action of muscles has a great share in producing them, the vio- 
lence done to the external parts is less, and the laceration of 
the soft parts is not so considerable: even in articulations of the 
same kind, the extent of the evil is measured by the largeness 
of the surfaces of the joint, the number and strength of the 
muscles surrounding it, and the thickness and number of its 
ligaments. It is for these reasons that luxations of the foot 
and knee are more dangerous than those of the elbow and 
wrist: the former require a much greater degree of external 
violence to produce them, in consequence of which the injury 
done to the soft parts is much greater. 



M ^ 
212 GENERAL TREATMENT OF LUXATIONS. 

A difficulty in reducing the luxated bone renders the luxa- 
tion more or less troublesome. With respect to this point, 
luxations of the round articulations are more unfavourable than 
those of the ginglymoidal; those of the femur more than those 
of the humerus, because the efforts to reduce the former are 
often counteracted by the action of very powerful muscles. 

Luxations arising from a swelling of the cartilages of the 
joints, from a caries of the bones, or from a relaxation of the 
ligaments, are always attended by more grievous consequences 
than those occasioned by external violence. Lastly, a contusion 
more or less considerable, laceration of vessels, or destruction 
of the substance of nerves, render the prognosis more or less 
unfavourable. The latter circumstance occasions a paralysis of 
the muscles to which the disorganized nerve furnished branches. 
We have seen, in a luxation of the humerus downwards and 
inwards, a paralysis of the deltoid muscle produced by the vio- 
lent contusion of the circumflex nerve, which is chiefly be- 
stowed on that muscle, 

SECTION V. 



General Treatment cf Luxations, 

To reduce the luxated bone, keep it in its place, and pre- 
vent or remove the symptoms with which the luxation may 
be complicated, form the three indications which are to be 
fulfilled in the treatment of luxations. The reduction is ac- 
complished, as in cases of fracture, by three means opposite in 
their a£tion, but tending to the same end, viz. extension, coun- 
ter-extension, and co-aptation. It is useless to repeat the de- 
finition of each of these terms, and in what each of these mo,-? 
tions consists. 

The reduction of a luxation is the most difficult and import- 
ant part of the treatment of it. Contrary to what takes place 
in fradlures, which are easily reduced, but difficultly kept so, 
luxations are hard to reduce j but when the bone is once ad- 
justed, it is easily kept in its place. It will not then be useless 
to examine minutely all the particulars of this operation: and 
first, with respect to extension, we will examine in order on 
what part the apparatus for making it should be applied, the 



GENERAL TREATMENT OF LUXATIONS, 21 3 

means employed for this purpose, the degree of force to be 
used, and the direction in which it is to be made. 

The extending force should be applied, not on the luxated 
bone, but on that with which it is articulated, and as far as 
possible from it. The observance of this precept is still more 
necessary in luxations than in fractures. 

All the ancient authors advised applying the extending force 
on the luxated bone; for instance, to apply it above the knee 
in luxations of the femur, and above the elbow in those of the 
humerus. Many of the moderns have followed their instruc- 
tions; and this mode is found recommended by J. L. Petit and 
Duverney, in their Treatises on the Diseases of the Bones. 
Two members of the Academy of Surgery, Fabre and Dupouy, 
saw the inconvenience of this practice, and substituted for it a 
mode of treatment now generally adopted. Their practice, 
which consists in applying the extending force on the bone that 
articulates with the luxated one, has two most important ad- 
vantages: first, the muscles that surround the luxated bone are 
not compressed, nor stimulated to spasmodic contractions, which 
would prevent the reduction, not only by opposing a force su- 
perior to that employed for the purpose of reduction, but also 
by retaining the head of the bone engaged in the interstices of 
the contracted muscles* Secondly, the extending force is much 
more considerable than can be obtained by the other mode; for, 
as Dupouy has observed, by elongating thus the arm of the 
lever, we acquire a degree of power, which the difficulties 
presented in a great number of cases often force us to have re- 
course to. 

It has been apprehended, it is true, that the extending force 
applied at a distance from the luxated bone, would lose in the 
articulations of the limb a part of its effect: thus, it has been 
said, that a part of the extending force applied at the wrist in a 
luxation of the humerus, is employed in elongating the liga- 
ments of the elbow joint. But this objection is ill founded: all 
the muscles which go from the humerus to the fore-arm, by 
strengthening the articulation of these bones, make it answer 
as a continued lever, along which the force is communicated 
without any loss. 

Force applied by the hands of intelligent and strong assist- 
ants, is preferable to any mechanical means in the reduction of 
luxations: the number of assistants may be increased at will, 
and the force proportioned to the resistance that is experienced : 
should there not be room for a sufficient number to grasp the 



214 GENERAL TREATMENT OF LUXATIONS. 

limb, they may pull by a napkin folded longitudinally, and 
tied on the limb. The quantity of force employed, though it 
is impossible to ascertain it exactly, is better known when we 
make use of a certain number of assistants, than when we use 
a pulley, which may act with such force without our perceiving 
it, as to lacerate the muscles, ligaments, and even the skin 
which covers the articulation, and thus occasion the most dire- 
ful sufferings. 

It is impossible to assign the precise degree of force to be 
employed: it is to be varied and proportioned according to the 
strength of the patient and the number and force of the mus- 
cles surrounding the articulation. It has been said, that in 
reducing a luxation there is occasion for more address than 
force: it would be true to say that the union of both is neces- 
sary. Often, six assistants accomplish that which three cannot 
do, and nine or ten perform that which cannot be done by six. 
But when the reduction cannot be effected by the number of 
assistants which in reason we suppose capable of overcoming 
the resistance, all further attempts must be suspended. The 
action of pullies, or any other machine analogous to them, 
would sooner tear the integuments than produce an elongation 
of the muscles. 

As to the direction in which the extending force is to be ap- 
plied: at first it should be the same as that which the disloca- 
tion has given to the luxated bone. In order to prove how 
indispensably necessary this rule is, let us suppose that the 
head of the humerus, luxated inwards, is forced into the fossa 
subscapularis, between the subscapulars muscle and the scapula : 
in this case, the elbow is not only moved out from the trunk, 
but even carried backwards. Now, should we commence the 
reduction by pulling in the natural direction of the humerus, that 
is, directly outwards, the head of the bone would be pressed 
against the fossa subscapularis, it would not slide along easily, 
the force would be spent in pushing the scapula backwards, and 
the irritation would excite the contraction of the muscles in the 
part where the head of the bone has been carried. 

Extension is then to be made at first in the direction which 
the luxated bone has taken; but in proportion as the muscles 
elongate and yield to the force acting on them, the bone is to 
be gradually brought back to its natural position; in this way 
the head of the bone is disengaged from the parts in which 
it has been placed, and is brought back to the cavity it has 



GENERAL TREATMENT OF LUXATIONS. 2 1 5 

left, by making it describe the same course it took in escaping 
from it. 

The best-directed extension will be useless, if the bone 
with which the luxated one has been articulated is not kept 
motionless by counter-extension, a force equal to the other, 
but made in a contrary direction. The counter-extending 
power applied to the luxated bone itself, would be attended, in 
almost every case, with the double inconvenience of producing 
a spasmodic contraction of the muscles, and preventing the 
elongation of them necessary for the reduction- Let us sup- 
pose that in a luxation of the thigh, the counter-extending 
fillet be applied in the fold of the groin of the diseased side, 
the consequence will be, that the rectus internus and adductores 
muscles, in a state of tension between the pelvis and thigh, 
will be curved inwards, and consequently shortened when 
their elongation is absolutely necessary; besides, the compression 
they experience will also increase their contraction. It must 
be, then, as in eases of fracture, on the part placed immediately 
above the luxated bone that we are to apply the counter-extend- 
ing force: It is made by means of fillets, pulled by a number of 
assistants, equal to that of those who make the extension. As 
to the direction in which this force is to be made, it should be 
always perpendicular to the surface of ths luxated joint. In a 
luxation of the elbow, for instance, the counter-extension should 
be made in a line parallel to the os humeri; and in a similar 
affection of the femur, this force applied to the pelvis should 
be made perpendicularly to the surface of the acetabulum. The 
same rule is to be observed with respect to the shoulder in lux- 
ations of the humerus, as will be mentioned in treating of par- 
ticular luxations. Counter-extension is in some sort a vis iner- 
tias; for this reason the most intelligent assistants should be 
placed to make extension, the degree of which should be 
directed by the surgeon. Coaptation is easily performed, when 
the extension is sufficient: in a luxation of the humerus, when 
the head of the bone is disengaged, and the assistants bring it 
hastily to its natural direction, the surgeon seizes the moment, 
and with one hand presses on the superior and internal part of 
the arm, whilst, at the same time, with the other he supports 
the elbow, and thus conducts the head of the bone into the 
glenoid cavity. If a luxation take place in a ginglymoidal arti- 
culation, as it is rarely complete, in such cases we use exten- 
sion and counter-extension only with the view of diminishing 
the friction of the surfaces of the joint, necessarily occasioned 



2l6 GENERAL TREATMENT OF LUXATIONS. 

by the opposite motions given them in order to place them in 
their natural situation. 

By an exact observance of the general rules just laid down, 
we shall be able, in almost all cases, to reduce luxations. How- 
ever, when the operation fails, notwithstanding the most judi- 
cious attempts to accomplish it, the cause of failure must be 
looked for. Sometimes it is owing to the insufficiency of the 
means employed; then we succeed by increasing the number 
of assistants, or by diminishing the muscular force of the pa- 
tient, which is done in various ways. 

Change of posture often produces this effect; we have seen 
patients, who, while seated on a chair, and supporting them- 
selves with the feet against the ground, could not have had 
their luxations reduced by the greatest efforts. By extending 
them on a long and settled table, their muscles, deprived of a 
centre of motion, yielded with an unexpected facility. 

If this means proves insufficient, the patient is to be repeat- 
edly bled, after short intervals; he is to use the warm bath, 
and be confined to a very low diet. At the end of twenty-four 
hours, when he is brought down by this treatment, the luxa- 
tion, before irreducible in appearance, may now be reduced with 
facility. The state of intoxication, induced by spirituous li- 
quors or opium, is favourable; the muscles attached to the 
luxated bone participate in the general debility, and elongate 
by the slightest effort. It is thus that Citizen Boyer alone, and 
at the first attempt, while the assistants were preparing the 
apparatus, reduced a luxation of the arm of an intoxicated pos- 
tillion. Some authors have even advised to intoxicate the pa- 
tients, when the luxations could not be reduced by the ordinary 
means; and cases have been met with, in which even this 
practice has failed. 

Lastly, one more resource remains, which has sometimes 
succeeded; it was first employed by Le Cat, in a luxation of the 
jaw, and consists in fatiguing, by continual action, the muscles 
which surround the luxated bone. It is well known that the 
contractile faculty of our organs is exhausted by exercising 
them too long, and that the frequent repetition of their con- 
tractions necessarily brings about a collapse: the surgeon just 
cited, availed himself of this fact. The levatores muscles 
of the lower jaw were spasmodically contracted, in a case of 
luxation of that bone, and would not admit of having it brought 
down : Le Cat introduced a smail stick between the teeth, and 



GENERAL TREATMENT OF LUXATIONS. 21*] 

making use of it as a lever, combated the action of the muscles, 
until they fell into a state of atony, and allowed him to accom- 
plish the reduction. David has derived similar advantages from 
the same practice, in luxations of the thigh and arm. This 
circumstance enables us to explain why a luxation that has re- 
sisted the fruitless efforts of an intelligent surgeon, aided by a 
sufficient number of assistants, afterwards yields to a much less 
considerable force, used by a less dexterous practitioner. 

With respect to luxations that have been mistaken, and not 
reduced for several days after the accident; the swelling of the 
ligaments, and other soft parts, the contraction of the hole in 
the capsule, through which the head of the bone passed, ren- 
der the reduction of them difficult, if not altogether impossible. 
The use of warm baths and pumping is then recommended, 
with a view of emptying, as it were, and rendering pliable, the 
parts about the joint: exercise should be combined with these, 
and the luxated bone should be kept in motion for some time 
every day, in order to disengage its head, relax the soft parts, 
and enlarge the opening by which it is to pass. 

All these endeavours are very often fruitless, in cases where 
more than a month has elapsed since the luxation. The term 
beyond which we cannot hope to reduce luxations of the gin- 
gtymoidal articulations, is much shorter; after twenty or twen- 
ty-four days, they are in general irreducible, from an anchylosis 
having taken place. 

We know that a luxation is reduced from the limb having re- 
covered its natural length, shape, and direction, and from the 
capability of performing certain motions impossible in luxations. 
The limb should not be moved but with the greatest caution: a 
relapse of a luxation of the humerus has taken place, and a 
second operation has been rendered necessary, by incautiously 
carrying the hand to the forehead by a semi-circular motion. 

The cessation of pain has been considered a sign of the bone 
having entered its natural situation: by cessation, we are to 
understand a remarkable diminution, rather than a total disap- 
pearance of pain. Lastly, the noise made by the head of the 
bone on entering its cavity, is an unequivocal sign of the luxa- 
tion being reduced. It is necessary to observe all these symp- 
toms, in order to be convinced that the reduction has taken 
place; by doing so we shall be seldom mistaken, though in- 
stances to the contrary have been sometimes met with. 

We very rarely fail to reduce a recent luxation, and perhaps 
there are none absolutely irreducible: thus we ought not to be 
28 



1-18 GENERAL TREATMENT OF LUXATIONS. 

discouraged, and desist, when we cannot easily obtain the re- 
duction, but multiply our means, and endeavour to surmount 
the obstacles. 

To preserve the luxated bone in its place, we have only to 
keep the limb without motion. Thus, as the humerus cannot 
be luxated but when it is at some distance from the body, a 
return of its dislocation will be prevented by tying the elbow to 
the lateral parts of the trunk. The bandage employed for 
keeping the limb motionless, should be applied on the oppo- 
site extremity of the bone. Thus, after a luxation of the arm, 
when we apply on the elbow the means for keeping the bone 
in its place, we act on that point of the humerus the most dis- 
tant from its articulation with the scapula, and the force thus 
applied to the extremity of the lever is much increased. The 
same rule should be observed in the application of a bandage 
to the chin, after a luxation of the jaw. This practice is pre- 
ferable to the use of the chevestre; consequently all authors re- 
commend it in this particular care; but they have overlooked, 
in other cases, the principle established above, and from which 
they derived such happy effects in the treatment of luxations 
of the jaw* Thus, the spica bandage for the scapula, and that 
for the groin, are very defective in cases of luxation of the arm 
and T thigh; for, by acting on the centre of motion of these 
bones, they are incapable of keeping them fixed. 

When the luxation arises from any internal cause, such as 
paralysis of the muscles, relaxation of the ligaments, or general 
debility., we endeavour to remove the cause by appropriate re- 
medies, and, at the same time, restore the luxated bone to its 
proper place, and keep it fixed. . 

Amongst the accidents with which luxations are complicated, 
contusion is certainly the most frequent. They may also be 
accompanied with inflammation, wounds, rupture of vessels, 
contusion of nerves, and even fracture. In treating in general 
of the latter, we have said, that in such case luxation always 
preceded the fracture; and that it was impossible to conceive, 
that a bone, in which a solution of continuity took place, could 
be luxated. The treatment to be adopted in this troublesome 
complication has been also pointed out. The other f.ymptoms 
supervening to luxations, are treated as if they were compli- 
cated with fractures; we have nothing then to add to what has 
been said on that subject. It is proper, however, to observe, 
that paralysis, arising from a contusion of the nerves, is a fre- 
quent consequence of luxations of the arm; and when we con- 



GENERAL TREATMENT OF LUXATIONS. 219 

sider the relation between the head of the humerus, and the 
brachial plexus, we are astonished that it does not happen of- 
tener than it really does. 

When a luxated bone is not reduced, sometimes it remains 
in the place into which it has been forced; but much of- 
tener it changes its situation: it is carried along by the action 
of the muscles, and is removed farther and farther from the 
cavity of the joint. It is in this way that in luxations of the 
thigh upwards and outwards, the glutei muscles, by making 
the convex surface of the head of the femur slide along the ex- 
ternal depression of the ilium, which it touches only by a small 
point, force up the bone, until the shortening of the limb is 
as considerable as the natural extensibility of the parts will 
admit. 

But whether the head of the luxated bone preserve its first 
position, or take another, the pressure it makes on the bone 
on which it rests produces two effects: the head of the one is 
flattened, while a depression is made in the other. The ca- 
vity of the joint sometimes preserves its natural state, and some- 
times its depth diminishes; the latter takes place when the 
head of the bone remains near its cavity, and compresses the 
circumference of it. The ligaments grow thick, their lacera- 
tions consolidate, and they acquire a greater consistence than 
natural. The muscles, impeded in then* action, lose their 
consistence, become of the nature of ligaments, and sometimes 
even are attached to the ligaments by a deposition of osseous 
matter, and thus form a kind of bony case, which constitutes 
with the displaced bone a new articulation. 

If the bone is not reduced, the limb remains deformed, and 
scarcely any use can be made of it for some months; but in time 
it gradually comes to its natural direction; and when the head 
of the bone has acquired a certain mobility in its new articula- 
tion, it is capable of considerable latitude of motion. Never- 
theless, the muscles, from being compressed and obstructed in 
their action, decay, and the size of the limb diminishes: this 
diminution is much more remarkable in children than in adults. 

This difference is so great, that it may be distinguished at 
first sight whether the accident happened during infancy or 
maturity. 



220 



CHAPTER V. 



OF LUXATIONS OF THE LOWER JAW. 

THIS bone can only be luxated anteriorly, whether one or 
both condyles escape from the glenoid cavities of the 
ossa temporum, with which it is articulated. Luxations of it 
are denominated complete or incomplete; but these denomina- 
tions are erroneous, as they would lead us to believe, that the 
bone may be luxated without its condyles being removed en- 
tirely from the glenoid cavities of the temporal bones. Every 
luxation, but that anteriorly, is rendered impossible by the 
natural conformation of the parts. In reality, before a luxa- 
tion backwards could take place, the maxilla inferior must be 
elevated above the point of contact of the arch formed by the 
teeth, and meet no opposition to its dislocation in this direc- 
tion from the osseous portion of the auditory canal; and further, 
it must be effected without the aid of any muscle. Luxations 
laterally, to the right or left, are equally impossible, on account 
of the resistance made by the spinous processes of the sphenoid 
bone, and the internal ligaments of the articulation. These 
ligaments, like all the others of the same part, would in truth 
afford a feeble resistance; for the muscles are here very evi- 
dently the principal means of strengthening the articulation: 
but, independently of these considerations, it is evident, from 
the form of the bone, that a blow given to it on its sides, tends 
rather, by increasing its curvature, to fracture it, than to lux- 
ate it. 

In very young infants, any luxation of the jaw is impossible : 
in them the body and branches of the bone meet at an obtuse 
angle. Now, from this conformation, it follows, that the con- 
dyles, the necks of which have nearly the same direction as 
the body of the bone, cannot, by any motion of the jaw, be 
moved out of their cavities; and, in order to produce a luxa- 
tion, the jaw should be pulled down,^ and the mouth opened 
to a degree which it could not admit of. Were it not for this 



OF LUXATIONS OF THE LOWER JAW. 121 

truly admirable disposition, how frequent would not luxations 
be at this period of life, either from the cries of the child, or 
from attempts to put too large bodies into its mouth! 

The causes of luxations of the lower jaw are very often in- 
ternal: rarely has it been seen, that a blow given from above 
downwards, or from before backwards, or a fall on the chin, 
has produced luxation of it; it almost always arises from ex- 
cessive yawning. In every great depression of the jaw, the 
condyles slide from behind forwards, under the transverse root 
of the zygomatic processes. The cartilaginous cap which en- 
velops the condyles, and follows them in all their motions, fur- 
nishes to them still an articular cavity: but the depression of 
the bone continuing, the ligaments give way, the condyles pass 
before the transverse apophyses, and thus fall into the zygo- 
matic depressions. In this motion, the angles of the jaw are 
raised and carried backwards, whilst the condyles are depressed 
and carried forwards; and the bone, as is well known, by turn- 
ing on an axis which may be supposed to pass through- its 
branches nearly about the middle of their height, performs an 
Imperfect revolution. 

The mode in which luxations of the jaw take place has been 
differently explained. Some have imagined, that the bone 
being forcibly carried down by the submaxillary muscles, and 
carried forwards by the pterygoidei externi, its coronoid apo- 
physes perched on the eminences of the cheek-bone and be- 
came a fixed point for the action of the levatores muscles, 
which dragged the condyles into the zygomatic depressions. 
But to prove how ill-founded this theory is, it is sufficient to 
observe, that in no case is the coronoid apophysis carried on 
the eminence of the cheek bone, and that even when the lux- 
ation has taken place, arj interval can be still felt between these 
two bony parts. 

When the mouth is shut, the axis of the maxilla inferior forms 
with a line drawn in the direction of the middle of the masseter 
muscle, an obtuse angle anteriorly, and a salient angle poste- 
riorly; consequently when this muscle contracts, in order to 
move the lower jaw, its action is decomposed, one part tends to 
elevate it perpendicularly, and the other to carry it forwards. 
In proportion as the jaw is depressed, and its angles, to the ex- 
ternal sides of which the masseters are attached, are carried 
upwards and backwards, the medium line of the direction of 
the bone tends to become parallel with that of the masseters; 
and if these muscles contract when the bone is in this position, 



222 OF LUXATIONS OF THE LOWER JAW. 

the greater part of their force is employed to bring the condyles 
into the zygomatic depressions. 

This explanation, very little different from that given by 
Citizen Pinel,* in a Memoir in which he applies geometry to 
explain the theory of luxations, appears to us much better than 
the preceding, which is found in a Treatise on Diseases of the 
Bones, and Surgical Operations, by Chopart and Desault. But, 
whatever may be the manner in which tne levatores of the jaw 
produce a luxation of this bone in its depressed state, the parts 
which surround the articulation are affected in the following 
manner: The condyles carried before the transverse root of the 
zygomatic processes into the zygomatic depressions, compress 
in a greater or less degree the deep-seated temporal nerves and 
those going to the masseters, which nerves, in their way to 
their destination, pass before the neck of these processes. This 
compression of the nerves by the condyles, explains the pain 
accompanying luxation of the jaw much more satisfactorily, than 
does the elongation of the masseters and other muscles to which 
they have been attributed. The tension of the masseter, tem- 
poral and internal pterygoid muscles, is not so considerable as to 
produce them. The pterygoideus externus is relaxed; the fee- 
ble ligaments which surround the articulation are in a state of 
tension, the interarticular cartilages accompany the condyles, 
and furnish them, even in the zygomatic depressions with a 
kind of cavity. The mouth is more cr less open. It is more 
so in recent luxations, than in those that have continued for 
some time. An empty space is felt before the ear, where the 
condyles were placed. The coronoid process forms under the 
cheek-bone an eminence which is felt through the cheek, or by 
introducing the finger into the mouth. The cheeks and tem- 
ples are flattened by the lengthening of the temporal, masseter, 
and buccinator muscles; the saliva flows in large quantities 
from the mouth, irritated by constant exposure to the air, 
which increases its secretions. The compression made on the 
salivary glands, and the irritation and friction they experience, 
contribute to render the secretion of the saliva still more abun- 
dant. The arch formed by the teeth of the lower jaw is placed 
anterior to that formed by those of the upper, and the direction 

* The Physical Journal'cf the Abbe Rozier contains many Memoirs of 
Citizen Pinefs en the same subject j we should have most wiliingly trans- 
ferred the results of them to this work, did it not require a greater shave 
of the knowledge of geometry to understand them, than is possessed by 
the generality of readers. 



CF LUXATIONS OF THE LOWER JAW. 22% 

of their edges shews that this disposition is unnatural. Lastly, 
the patient can neither speak nor swallow during the first days 
of the luxation. 

The symptoms just pointed out, hnd which are sufficient to 
enable us to establish a clear diagnosis when the luxation is 
recent, are far from being so well marked when the disease has 
continued several days or weeks. In these cases the jaw is ele- 
vated insensibly, and approaches the maxilla superior; the pa- 
tient recovers by degrees the faculty of speech and deglutition, 
but he still stammers, and the saliva drivels from his mouth. 
A luxation of the jaw is far then from presenting circum- 
stances from which we are to form so unfavourable a prog- 
nosis as that made by Hippocrates, who says that it is fatal, 
unless reduced before the tenth day. Perhaps trismus, or lock- 
jaw, which is much more dangerous than luxation, has been 
confounded with it. The extreme facility with which these 
luxations take place in some persons, does not render the prog- 
nosis more unfavourable; in such the reduction is easily effected, 
and often there is no necessity for having recourse to profes- 
sional men to accomplish it. Lastly, the operation of reduct- 
ion is in all cases simple, and certainly successful when it is 
done after the following manner: 

The patient is to be seated on a low stool, with his head 
supported against the breast of an assistant, who, by placing 
his hands across the forehead, is to fix the head. In this po- 
sition of the patient, the surgeon's hands are on a level with 
the mouth; which is advantageous, because he is not obliged 
to elevate them, and consequently can act with greater force 
on the jaw. The surgeon, after securing his thumbs with 
linen, to prevent being pained by the compression he makes on 
the teeth, introduces them into the mouth, and places them as 
far back as possible on the great molares, at the same time 
bending under the chin the four fingers of each hand. If there 
is not room for all the fingers he uses, at least, the index and 
middle finger. Having thus seized the jaw, he presses with 
his thumbs on the great molares, brings the jaw downwards 
and backwards, and disengages the condyles from the zygo- 
matic fossse into which they were carried. When the muscles 
obey this effort, and it is found that the condyles yield to it 
and descend, the chin is to be elevated by the fingers; thus 
converting the bone into a lever of the first kind. In elevating 
the jaw, it is to be pushed backwards. 

When the extension has been effectual, that is to say, when 
the muscles are elongated by tke* effort, to depress the bone. 



224 OF LUXATIONS OF THE LOWER JAW. 

they contract spasmodically the moment that the condyles are 
disengaged from the zygomatic fossae, and bring these processes 
into the glenoid cavities so rapidly and forcibly, that there 
would be danger of having the thumbs much bruised by the sud- 
den approximation of the teeth, if the precaution were not 
used of quickly directing them outwards, and placing them be- 
tween the cheek and the jaws. 

When the luxation is reduced, which is known by its cha- 
racteristic symptoms disappearing, and especially by the jaws 
coming together in their natural manner, a relapse is prevented 
in this way: the chin-bandage is to be applied, to prevent the 
motion of the bone, which it does in a most effectual manner, 
as it resists the muscular action that tends to produce it at the 
point the farthest removed from the centre of motion. This 
bandage is not to be removed but when the patient takes food. 
During the first days, the aliments should be liquid, or such as 
require no mastication. When solid food can be used, the pa- 
tient should be careful to support the chin with his hand each 
time that he wishes to depress it. 

We have mentioned in the preceding chapter the manner in 
which Le Cat succeeded in reducing a luxation of the jaw, viz. 
by fatiguing the muscles. This means would be proper in a 
similar case, and should be had recourse to. 

Let us mention here, in order to censure it, the practice of 
reducing luxations of the jaw, by giving a blow of the fist to 
the under part of the chin. Some, however, say, that this 
defective mode has sometimes succeeded; but it is easily per- 
ceived that the blow given from below upwards, tends to force 
the condyles deeper and deeper into the zygomatic fossae, and 
that, given from before backwards, it may fracture these pro- 
cesses. 

The ancients placed two pieces of stick between the great 
molares, and acting with them as levers to depress the lower 
jaw, they elevated the chin by means of a bandage, the ends of 
which met on the top of the head. This process, described 
with much perspicuity by Devigo, is extremely methodical; it 
is not, however, preferable to that of the moderns, which, 
more simple than it, has still the advantage of not exposing the 
teeth to be broken by the sticks, at the moment when the con- 
dyles re-enter their cavities. 

In luxations which have been called incomplete, that is to 
say, when only one condyle has escaped from its cavity, the 
treatment requires so little modification, that I do not think it 
necessary to enter into further details on this subject. 



225 



CHAPTER VI. 



OF LUXATIONS OF THE VERTEBRAE. 

THE large surfaces by which these bones correspond, the 
number and thickness of their ligaments, the strength 
of the muscles lying on the column formed by them, the small 
motion of which each vertebra is capable, and lastly, the ver- 
tical direction of their articulating apophyses, render a luxation 
of them in the dorsal and lumbar part of the column, entirely 
impossible. A violence, though ever so considerable, cannot 
displace them without first fracturing them. The same is not 
the case with the cervical vertebra?; the extent of their articu- 
lating surfaces is less, the ligamento-cartilaginous substance 
which unites their bodies has more pliability, the motion of their 
articulations is greater, and their articulating surfaces have an 
oblique direction, which allows them to have an obscure rota- 
tory motion; consequently luxations of them are sometimes 
met with. I have seen a case in which the neck was luxated 
by a violent rotatory motion of the cervical vertebra?, and the 
luxation resisted all means that were employed to reduce it. 
The cause of impediment was felt towards the middle of the 
column formed by the cervical vertebras; from which circum- 
stance we may conclude that the dislocation did not consist of 
a separation of the first vertebrae from the second, which is 
admitted to he possible by all authors, but that it took place 
lower down in the cervical part of the column. 

It appears from well-attested facts, that luxations may take 
place in the vertebral column; such as those of the head from 
the first vertebra, andi of the first vertebra from the second. 
These, and especially the latter, are the most frequent; but 
Others, though much rarer and more difficult, may however 
take place. 



29 



26 OF LUXATIONS OF THE FIRST 



SECTION I. 



Of Luxations of the Head from the first Vertebra. 

The articulation of the occipital bone with the first vertebra 
of the neck is strengthened by means of many ligaments, and 
admits of only very limited motions. It is well known, that 
the motions of inclination of the head to the right and left, and 
of flexion and extension, take place along the whole length of 
the cervical vertebra?. We have no instance of luxation of the 
head from the first vertebra by an external cause; such a dislo- 
cation, if possible, would instantly destroy the individual to 
whom it happened, by the compression and disorganization of 
the spinal marrow. But nature, which cannot bear so sudden 
a change, is habituated to it when it takes place gradually and 
insensibly; and the spinal marrow, which a sudden though in- 
considerable derangement of the spine would totally disorganize, 
is not sensibly injured when it takes place by degrees; cases of 
rachitis furnish us many proofs of this. It is only in this way 
that we can explain how the individual from whom the prepa- 
ration in the Museum of Natural History was taken, could ex- 
ist until such very great deformity took place in his spine. 



SECTION II. 



Of Luxations of the first cervical Vertebra from the second. 

It is principally in the triple articulation of these two verte- 
brae, that the motion of rotation of the head to the right or left 
takes place; for the union of the first vertebra to the occipital 
bone is so close, that the motion of both is th • same. This 
rotation of th? first vertebra on the second, which the laxity 
and weakness of the ligaments that go from one to the other, 
and the direction of their articulating apophyses, render easy, 
would be frequently carried beyond its natural bounds; and 
luxation would take place every time we turn our head with 
force, if the motion were not confined by two very thick liga- 



CERVICAL VERTEBRA FROM THE SECOND* 227 

merits, which go from the sides and summit of the toothlike 
process of v the second vertebra to the edges of the great occipital 
hole. When this motion is forced beyond its proper limits, 
the ligaments are torn, and the lateral parts of the body of the 
first vertebra glide along on the articulating horizontal pro- 
cesses of the second If the head is turned from the left to the 
right, the left side of the body of the vertebra is carried before 
its corresponding articulating surface, whilst the right side falls 
behind its corresponding surface. In this luxation, sometimes 
the toothlike process, the ligaments of which are broken, leaves 
the ring formed for it by the transverse ligament and the an- 
terior arch of the first vertebra, and presses on the spinal mar- 
row, the substance of which it destroys; at other times it re- 
mains on its ring, but the diameter of the vertebral canal is 
always diminished at this place, and the spinal marrow expe- 
riences a compression, and at the same time a contortion, by 
which it is lacerated It is easily conceived that the patient 
cannot survive a derangement of this nature; every lesion of 
the spinal marrow at this height is quickly fatal. Louis, in 
making researches on the manner of dying of hanged persons, 
found that those despatched by the executioner of Lyons, pe- 
rished by the luxation of the first vertebra from the second; 
whilst those hanged at Paris were suffocated by strangulation. 
He discovered the cause of this difference in a rotatory motion 
given to the body of the culprit by the executioner of Lyons, at 
the moment that the ladder was taken from under his feet. 
We ought to attend to this observation, when we examine in 
a judicial capacity the body of a person found hanged. We 
should carefully examine the second vertebra, and see if it be 
luxated. If so, the individual has not been guilty of suicide, 
for the luxation must have resulted from a violent motion com- 
municated to the body by the assassins. 

The following case given by J. L. Petit, furnishes an instance 
of luxation produced by the motion occasioned by the person 
himself; the circumstances of it are so extraordinary, that we 
shall relate them at full length. 

" The only son of a tradesman, aged between six and seven 
" years, went into a neighbouring shop, the proprietor of which 
" was a friend of his father's. This person playing with the 
" child, put one hand under his chin and the other on the back 
* c of his head, and then raised him up in the air, telling him 
" that he was going to shew him his grandfather, a common 
Cf expression among the vulgar. Scarcely was the child raised 



228 OF LUXATIONS OF THE FIRST 

" from the ground, when he began to struggle, and by his 
" efforts dislocated his neck, and died on the spot. The father, 
" on hearing of the death of his child, ran in a fit of passion 
" after his neighbour, who fled before him, but not being able 
U to catch him, he threw at him a sadler's hammer which he 
" had in his hand, and buried the cutting part of it in the de- 
" pression of his neck. The weapon cut all the muscles, pe- 
" netrated into the space between the first and second cervical 
a vertebra, divided the spinal marrow, and occasioned almost 
u instantaneous death. Thus both perished nearly in a similar 
" manner." J. L. Petit, who quotes no authority to support 
this fact., avails himself of the opportunity of censuring this 
dangerous sort of play, and observes with justice, that the mo- 
tion which the child gave himself was the cause of his death. 

The relaxation of the ligaments of the toothlike process may 
favour this luxation. Such probably was the case of a young 
man, who found a difficulty to bring his head back to its natural 
posture, each time that he turned it to the right or left. There 
are many cases of luxation of the neck, in which death does 
not succeed the accident; but in these, the dislocation takes 
place in the third, fourth, fifth, or sixth vertebrae, and only 
one articulating process is luxated: in these cases, the diameter 
of the vertebral canal is not so much diminished as to compress 
the spinal marrow, and destroy life; but a wry-neck remains, 
which becomes incurable, unless the real cause of it be found 
out. 

A child, whilst playing on his mother's bed, suddenly felt 
pain in his neck, accompanied with a distortion, which he could 
not remove. Desault, to whom the child was brought, disco- 
vered a luxation of the vertebrae of the neck; but before trying 
to reduce it, he informed the mother that the child might die 
in the attempt. This information terrified the mother so much, 
that she took away her child without having any thing done to 
relieve it. 

A lawyer writing at his desk, heard the door behind him 
open; he quickly turned round his head to see who was co- 
ming in, but could not bring it back again to its natural direct- 
ion. Many surgeons of Paris have seen this patient: his head 
was turned to the right, and slightly inclined to the shoulder 
of the same side, This inclination was much less than it would 
have been in a spasmodic contraction of the sterno-cleido-mas- 
toideus muscle. 



CERVICAL VERTEBRA FROM THE SECOND. 229 

Thus, when, in consequence of a sudden and violent effort, 
the head is found turned to one side, either right or left, with 
inability to bring it back, the ear a little inclined to one side, 
and the sterno-cleido-mastoideus in a state of relaxation, there 
can be no doubt but that a luxation of one of the cervical ver- 
tebra has taken place. 

If the luxation produce no symptom which indicates a com- 
pression of the spinal marrow, it is prudent to abstain from all 
attempts to reduce it. However, if the patient absolutely insist 
on our interfering, we are to proceed in this way: we begin by 
inclining the head to the side towards which it is directed, in 
order to disengage the articulating process of the upper verte- 
brae: this part of the operation is extremely dangerous, as it 
may kill the patient by causing a compression on the spinal mar- 
row. When the process is disengaged, the head and neck are 
brought to their right direction, by making them perform a ro- 
tatory motion the contrary of that which had taken place in the 
luxation. A relapse is prevented by keeping the head free from 
motion. This is done by means of bandages, which are at- 
tached to the head and shoulders. 



CHAPTER VII. 



OF LUXATIONS OF THE BONES OF THE PELVIS. 



NONE of the assemblage of bones which form the pelvis, 
are susceptible of a true luxation. It is impossible that 
the os sacrum, inclosed between the two ossa innominata, can 
abandon the position in which it is confined by such powerful 
means. The os coccygis, which has more motion, is easier 
fractured than luxated. Citizen Boyer has however observed a 
derangement of it, in a man greatly emaciated in consequence 
of long disease: he had considerable ulcerations in the neigh- 
bourhood of the coccyx, and the bone itself was laid bare by 
the separation of a large gangrenous eschar. There was an 
interval of nearly two inches between the summit of the sacrum 
and the base of the os coccygis. But in proportion as he re- 
covered strength, the bone was drawn backwards, and was at 
last united to the sacrum, notwithstanding the action of the 
levatores ani which are attached to it. The ossa innominata 
are too firmly articulated with one another, and with the sa- 
crum, to admit of luxation; however, the symphysis pubis and 
sacro-iliac synchondrosis, which in the natural state admit of 
no motion, may be so relaxed, or the ligamento-cartilaginous 
substance which unites them may be so far destroyed, and the 
bones thereby rendered so moveable, that progression, which 
requires the firm union of these bones, becomes difficult. Is 
this relaxation of the articulations, and the consequent seceding 
of the bones, a means employed by nature to increase the dia- 
meters of the pelvis, and facilitate parturition? Louis has shewn, 
in a dissertation, which is found in the first part of the fourth 
volume of the Memoirs of the Academy of Surgery, how many 
different opinions authors have on this subject. Some, in re- 
ality, suppose that the relaxation of the articulations is the na- 
tural state towards the end of pregnancy; others consider it as 
being always morbid. Were we permitted to give an opinion 



OF LUXATIONS OF THE PELVIS. 23 1 

on this subject, which comes chiefly under the cognizance of 
accoucheurs, we would say, that the symphysis pubis and the 
sacro-iliac synchondrosis' abound with juices, and are swelled 
and relaxed in a remarkable manner, in most women during 
pregnancy, that this relaxation seldom goes so far as to allow 
the bones to move and be separated; and lastly, that the mo- 
tion or separation of the bones is to be considered rather as a 
morbid than natural state. 

A lady was suddenly delivered of a child, without almost any 
pain : but the ovum came away entire, and with such rapidity, 
that the women in the chamber could scarcely reach her in 
time to receive it. No bad symptom supervened until the 
fourth day: at this time a fever appeared, and the patient died 
on the seventh day. Citizen Boyer, on opening the body, per- 
ceived that the ossa pubis were moveable, and remarked this 
circumstance to Citizen Baudelocque. Curious to discover the 
cause of it, they divided the symphysis pubis, and found a great 
vacuum in the centre of it, round which the relaxed ligamento- 
cartilaginous substance formed a raised margin, which was made 
to puff up by the approximation of the ossa pubis. In every 
other particular the pelvis was well formed, and the woman 
had had many easy deliveries. 

When a woman, towards the end of pregnancy, after partu- 
rition, or during any other time, feels pain in the articulations 
of the pelvis, and the mobility of the bones renders progression 
difficult and tottering, she should be confined to her bed, the 
pelvis should be surrounded with bandages drawn very tight, 
and the region of the pubis should be covered with astringent 
applications; but as these latter adl only on the external surface, 
we are to expect much less from them than from corroborants 
administered internally, and the use of bandages. 

The treatment suited to a relaxation of the symphysis pubis 
is also adapted to that of the sacro-iliac synchondrosis. We do 
not believe that a sudden and violent separation of the thighs 
can produce a disjointing of the latter, though a case of this 
kind is given in the Anatomico-surgical Observations of Blasius. 
It is probable that the motion of the bones in this case took 
place from the laxity of the ligaments; and this seems to be 
proved by the history of the patient, who was a young student 
in law, and, as Blasius expresses it, of an effeminate constitu- 
tion and a relaxed and delicate habit. 

But that which a sudden and violent separation of the thighs 
cannot produce may be occasioned by external violence. Louis's 
Dissertation, cited above, is terminated by the following case; 



2^2 OF LUXATIONS OF THE 

A sack of wheat, of three hundred and fifty pounds weight, 
fell on the back of a labourer who was unloading a waggon. 
The posterior part of the pelvis, on which the weight fell, was 
very much shaken; however, the pain was so inconsiderable, 
that it was only after some days that the patient sought relief. 
The bad symptoms now increased rapidly, and he died on the 
twentieth day. On opening the body, the os ilium of the right 
side was found separated from the sacrum, passing nearly three 
inches behind it; the parts contained in the pelvis were in- 
flamed, there was an effusion of purulent matter into the lower 
region of the abdomen, and the luxated bones moved freely on 
one another. 

The possibility of a luxation of the sacro-iliac synchondrosis 
by external violence is then proved beyond all doubt; but it 
must be very rare; and in the particular case just related, no- 
thing less than a very great weight favoured by the position of 
the pelvis could have caused it. An antiphlogistic treatment is 
particularly adapted to such cases; for the danger depends on 
the inflammation which must necessarily follow such considera- 
ble external violence, and which, if it extend to the organs 
contained in the cavity of the pelvis, may produce the worst 
consequences. The accession of inflammation should, if pos- 
sible, be prevented; if not, it becomes quickly fatal, unless it 
is arrested in its progress by copious and repeated bleedings, the 
use of warm baths, emollient fomentations, and the most rigid 
abstinence. 

As to the supposed luxations of the ribs admitted by some 
authors, we should have observed, respecting them, the same 
silence as J. L. Petit, did not a case inserted in the Memoirs of 
the Academy of Surgery, after the death of that celebrated prac- 
titioner, seem to establish the possibility of their taking place. It 
is not, however, difficult to perceive, in reading this case, that the 
surgeon who has given it has committed a strange mistake, by 
taking a simple fracture of the posterior extremity of these bones 
for a luxation of them. If we attend to the number and force of 
the ligaments which attach the ribs to the vertebrae and ster- 
num, and also to the manner in which the intercostal and other 
muscles confine them, we shall not easily conceive how external 
violence, whether it acts on their middle or extremities, can 
luxate them. They are so firmly attached to the surrounding 
parts, that it is very difficult to separate them from the body 
in the dead subject; and in preparing skeletons, we often break 
them if we are not careful to cut all their bonds of union be- 



BONES OF THE PELVIS. 2JJ 

fore we attempt to detach them from the parts with which they 
are articulated. All the symptoms presented by the case of the 
patient of Buttet, surgeon of Etampes, indicate a fracture of 
the neck or posterior extremity of the rib; the pain, crepita- 
tion, and motion of the bone, are characteristic marks of it. 
The author proves nothing by saying, that the noise arising 
from the motion of the rib was very distinct, and heard by him- 
self and his assistants, whilst that which characterizes fractures 
is only sensible to the hands, and that the rib could be moved 
in its whole length. First, it cannot be conceived how the 
noise which accompanies the motion of fractured bones can be 
sensible to the organ of touch. Next, the fracture having taken 
place very near the posterior extremity of the rib, rendered it 
impossible to draw any conclusion from its motion, as in this 
case it would have the appearance of moving entirely along its 
length; besides, it is very difficult to feel this motion through 
the muscles of the spine. Thus we regard luxations of the 
ribs as totally impossible, though Ambrose Pare, and after him 
Barbette, Junker, Platner, and Heister, admit them, and give 
different species of them. 

We must not, with Lieutaud, give this name to affections 
in which the body of the dorsal vertebrae and the head of the 
rib are separated from one another by a caries of these parts. 

It might happen, that by a violent and sudden contraction 
of the pedtoralis major, the cartilage of the sixth true rib, to 
the whole extent of which this muscle is attached, might be 
separated from that of the seventh; and that the very thin cap- 
sule which keeps them together might be torn. The paia 
alone would point out this affection. With respect to the 
depression of the other cartilages, and of the appendix xypho- 
ides, we refer to what we have said on that subject in treating 
of fractures of these parts. 



$0 



*34 



CHAPTER VIII 



OF LUXATIONS OF THE CLAVICLE. 

LUXATIONS are in general much less frequently met 
with than fractures. How numerous are fractures of the 
body and neck of the femur compared to luxations of this bone ! 
A surgeon, who has seen hundreds of the former, generally 
meets in the course of a long and extensive practice only a very 
few cases of primary luxations ©f the thigh. These general 
considerations apply, in a certain degree, to the bone, the lux- 
ations of which form the subject of this chapter. We find) in 
fact, that fractures of the clavicle are much mere frequent than 
luxations of it, and it has been supposed that they bear a pro- 
portion to one another of 6 to 1. These luxations are distin- 
guished into that of the extremity next the sternum, and that 
of the extremity next the humerus. 



SECTION I. 



Of Luxations of the Extremity next the Sternum. 

This extremity presents a large surface, which is articulated 
with another much smaller in the lateral and superior part of 
the sternum. This disproportion in the articulating surfaces 
disposes to dislocations, which are also favoured by the weak- 
ness of the ligaments, and the motions and functions of the 
joint. It is, in fact, in thi^ articulation, furnished internally 
with an inter-articular cartilaginous lamina, that all the efforts 
made by the superior extremity terminate. 

The clavicle may be luxated at this extremity forwards, back- 
wards, and upwards, but never downwards: the cartilage of 
the first rib borders its extremity on this side, and renders a 



OF LUXATIONS OF THE CLAVICLE. 235 

luxation of it in this direction impossible. Of the three possi- 
ble kinds of luxation, that anteriorly is the most frequent, and 
indeed almost the only one met with. To effect it, it is only 
necessary that the clavicle, naturally directed backwards, be 
carried still more in that direction: this motion of the shoul- 
der backwards is the easiest and most extensive of any of which 
this part is capable. Accordingly, nature has diminished, as 
much as in her power, the tendency to dislocation which results 
from it, by giving great force to the anterior ligament, which 
is still strengthened by the portion of the sterno-cleido-mastoi- 
deus attached to the sternum. Luxations backwards and up- 
wards are very rare: to effect the former, the shoulder must have 
been pushed forwards violently and to a considerable distance, 
and at the same time suddenly depressed by a great force: a 
combination of these circumstances sometimes takes place in 
falls. Lastly, of the two luxations upwards and backwards, 
the latter is that most rarely met with. 

If the shoulder be pushed violently backwards, the extremity 
of the clavicle next the sternum is carried forwards, lacerates 
the capsule of the articulation, the anterior ligament, and the 
tendon of the sterno-cleido-mastoideus muscle, abandons the 
surface it was articulated with, and passes before the superior 
part of the sternum; forming under the skin, the only covering 
at this place, a hard, projecting, circumscribed tumour, which 
follows the motions of the shoulder. The force which causes 
the luxation will act with the greatest advantage, if applied to 
the point of the shoulder, which is the part the most distant 
from the articulation in which the dislocation takes place. A 
baker's boy, in order to repose himself, rested his basket full of 
bread on the parapet of a bridge: the basket lost its equilibrium, 
and was falling backwards; the boy endeavoured to oppose it, 
and in the effort, the straps which passed under each arm-pit 
acted so powerfully on the point of his shoulders, that one of 
his clavicles was luxated forwards. 

When the shoulder is suddenly depressed, the extremity of 
the clavicle next the sternum is luxated easily upwards, as there 
is nothing to limit its motion in this direction, except the inter- 
clavicular ligament ; which, however, being relaxed by the 
greater contiguity of the two bones, makes only a very feeble 
resistance. 

In the luxation backwards, the extremity of the clavicle is 
carried behind the superior part of the sternum; but in this, as 
in the two preceding, all the ligaments that surround the aili- 



2j6 OF LUXATIONS OF THE CLAVICLE'. 

dilation are torn: this is the case, even with the costo-elavicular 
ligament, which does not immediately belong to it. This la- 
ceration, with the peculiarity of structure, renders the treat- 
ment of this luxation difficult. 

The superficial situation of the clavicle renders a diagnosis 
very easy. If the luxation be forwards, a hard circumscribed 
tumour is felt, or even seen, on the anterior and superior part 
of the sternum, which is made to disappear by carrying the 
shoulder forwards and outwards; and an empty space is found 
where the head of the clavicle should be placed, &c. &c. In 
luxation upwards, the space between the sternal ends of the 
clavicles is diminished. If the luxation be backwards, there is 
a depression at the place where the extremity of the clavicle 
should be placed, and a tumour is formed by it at the anterior 
and inferior part of the neck, which, as J. L. Petit observes, 
may compress the trachea arteria, oesophagus, jugular vein, ca- 
rotid artery/ and nerves; lastly, the head is inclined towards 
the affected side. By attending to these appearances, and to 
the history of the circumstances, we shall be able to ascertain 
the existence of the dislocation, and find out in what direction 
it has taken place. 

A luxation of this extremity of the clavicle is reduced in the 
same way as a fracture of this bone; that is, by making a lever 
of the arm, by means of which the shoulder is brought out- 
wards; and when the shoulder is brought outwards in this 
manner it is pushed forwards, if the luxation has taken place 
in that direction; backwards, if it be posteriorly; and we elevate 
it if the bone is dislocated upwards. By these means we make 
extension, disengage the extremity of the bone, and bring it 
towards its corresponding articulating surface: when in this 
state, by pressing on it with the Jiumb, it is restored to its 
natural situation; but it is as difficult to keep it in its place, as 
it is easy to reduce it. All the ligaments being more or less 
lacerated, the articulating surfaces, which are smooth and dis- 
posed obliquely, slide easily on one another from the least mo- 
tion of the shoulder. 

The apparatus used in fractures of the clavicle is to be applied 
in cases of luxations of the extremity next the sternum. . But 
it must be observed, that this apparatus, which makes a conti- 
nued extension by means of the cushion placed in the axilla, 
though ever so well applied, will not keep the clavicle exactly 
in its place; and notwithstanding the greatest assiduity of the 
surgeon, the luxated extremity will remain more prominent 



V 



OF LUXATIONS OF THE CLAVICLE. ' 237 



than that of the opposite side. This slight and inevitable de- 
formity would not be prevented, even though the tourniquet 
proposed by Brasdor to make pressure on the extremity, and 
thus keep it reduced, were used. It will be necessary to con- 
tinue the use of the bandage for a considerable time, in order 
to favour the union of the lacerated ligaments. 



SECTION 11. 



Of Luxations of the Extremity next the Humerus. 

These luxations, less frequent than the former, take place 
by a mutual sliding of two oblique and small surfaces on one 
another, which form the articulation of the humeral extremity 
of the clavicle with the acromion of the scapula. As these ar- 
ticulating surfaces are turned upwards, luxation seldom takes 
place but in this direction; it is proved, however, that it may 
take place downwards, and that the extremity of the clavicle 
may slide and pass under the acromion. The very great force 
of the conoid and trapezoid ligaments which unite the clavicle 
to the scapula, renders luxations of the humeral extremity very 
rare. The dislocation upwards, the only one that merits par- 
ticular consideration, may be occasioned by a fall on the summit 
of the shoulder; in which case, the humeral extremity of the 
clavicle slides upwards on the facet of the acromion, and mounts 
on this process, which is itself caried a little under the displaced 
bone, when the shoulder is drawn inwards by the action of 
the muscles which bring the arm near the body. In this lux- 
ation, the capsule, the superior ligament of the articulation, as 
also the aponeurotic expansion of the trapezius and deltoid 
muscles, and the conoid and trapezoid ligiments, are ruptured. 

This luxation, which is always occasioned by falling on the 
shoulder, may be said so be produced by the violence of the fall 
and the action of the trapezius muscle. This muscle, the fi- 
bres of which are attached to the external half of the clavicle, 
contracts, and tends to elevate the shoulder, and bring it back- 
wards; but as the shoulder is forced against the ground, and 
cannot obey this action, the conoid and trapezoid ligaments are 
torn, and the humeral extremity of the clavicle displaced. This 
explanation will not appear improbable to those who know 



23$ OF LUXATIONS OF THE CLAVICLE. 

what prodigious force muscles, in appearance the weakest, ex-' 
ert, and what enormous resistance they sometimes surmount. 

The existence of this luxation is easily assertained. If there 
be pain in the top of the shoulder succeeding to a fall on that 
part; and if, on examination, the extremity of the clavicle be 
found projecting under the skin covering the acromion, we 
may be sure it has taken place. Besides, the patient inclines 
his head to the affected side, and moves as little as possible ei- 
ther the arm or shoulder, because he cannot move these parts 
without calling into action the deltoid or some other muscle, 
which would consequently extend the motion to the diseased 
part, and cause pain. This luxation is not attended with such 
dangerous consequences as those related by Ambrose Pare. He 
says,* the bone cannot be reduced, the patient will remain dis- 
abled, and will never be able to carry his hand to his mouth or 
head. In fact, the clavicle has been often but imperfectly re- 
duced, and the patients were not disabled; and this is what is 
observed even in the greater number of cases: the ligaments 
heal without uniting, and the luxation relapses as soon as the 
bandage is removed. I have seen a person who had a luxation 
of this kind, and who, after five months regular treatment, 
could not move his arm without dislocating the clavicle; when- 
ever he used his arm, the scapula was carried backwards, and 
its base raised up the skin. 

We reduce this luxation by carrying the arm outwards, by 
putting a cushion in the axilla, and applying Desault's bandage 
for fractures of the clavicle, in such a manner as that all the 
turns of it which ascend from the elbow to the shoulder may 
bear on the luxated extremity, compress it, and keep it in its 
place. 



Works of Ambrose Pare, chap. F. of Luxations of the Clavicle. 



239 



CHAPTER IX 



OF LUXATIONS OF THE OS HUMERI. 

THERE is no articulation which admits of such extensive 
motion, as that of the humerus with the scapula: conse- 
quently, luxations of the former are extremely frequent: their 
number equals, if not exceeds, that of the luxations of all the 
other bones. The head of the humerus, a large hemispherical 
body, is not, properly speaking, entirely received in the gle- 
noid cavity of the scapula, which, notwithstanding the fibrous 
margin with which it is surrounded, is not deep enough for 
this purpose, It touches this cavity by only a very few points; 
the greater part of its surface is in contact with the orbicular 
ligament. The articulation itself, though admitting of great lati- 
tude of motion, is by no means provided with very strong liga- 
ments; it derives its principal strength from the orbicular liga- 
ment, and an accessary one which comes from the coronoid 
process of the scapula. These circumstances, render dislocations 
of the arm so easy, that, were it not for the great mobility of 
the scapula, which follows the humerus in all its motions, the 
latter would be dislocated by every trifling effort. The mobility, 
then, of the articulating surfaces diminishes the frequency of 
luxations, which are favoured by so many circumstances. 

The humerus can be luxated only in three directions, down- 
wards, inwards or forwards, and outwards or backwards. Lux- 
ation upwards, admitted by some authors, is rendered impossible 
by many causes: first, the acromion and coracoid process form, 
w r ith the triangular ligament which goes from the one to the 
other, a kind of vault over the articulation; therefore, the first 
effect of every effort to push the humerus upwards, would tend 
to fracture these two processes, and tear their ligament; and as 
the head of the humerus should be carried at once upwards and 
outwards, before it could be luxated in this direction, the trunk 
prevents this disposition of the parts by not allowing the elbow 
to be brought sufficiently inwards. Lastly, the tendons of the 



240 OF LUXATIONS OF THE OS HUMERI. 

biceps and supraspinatus, and the fleshy mass cf the deltoid 
muscle, efficaciously prevent this luxation. There is even one 
of the three species of luxation of the humerus, of which, 
though it has been described, and the possibility made evident, 
we are not acquainted with a single instance: it is the luxation 
outwards or backwards. The other two then are those that 
merit the attention of practitioners: the first is oftener met 
with than the second; it is even so frequent, that many authors, 
conformably to the opinion of Hippocrates, think that every 
primary luxation of the humerus takes place downwards: we 
say primary luxation; for the possibility of a subsequent change 
of place, by which the head of the luxated humerus is carried 
forwards, is generally admitted. In order to explain this sub- 
sequent change of place, let us suppose the head of the hume- 
rus, in a luxation downwards, to be placed between the tendon 
of the long portion of the triceps, and that of the subscapularis; 
but by a fall or muscular action, to be pushed forwards and 
inwards, and obliged to lodge between the fossa subscapularis 
and the muscle of that name. Luxation downwards can never 
be converted into that backwards; though the contrary opinion 
is supported by J. L. Petit; but, respectable as his authority 
may be, we easily conceive that the resistance made by the 
tendon of the long portion cf the triceps must prevent it. 

Luxation of the humerus downwards is the most frequent, 
not only on account of the great extent of motion of the bone 
necessary to produce it, but also because the lower part of the 
orbicular ligament is the thinnest and weakest, and the least 
supported. The tendons of the supraspinatus, teres minor, 
and subscapularis, are in some sort confounded with the orbi- 
cular ligament before they are inserted into the tuberosities of 
the humerus, and thus increase, in a remarkable manner, its 
strength and thickness on the superior side; the tendons of the 
teres minor and infraspinatus support the head of the bone on 
the outside; above, the same purpose is answered by the ten- 
don of the supraspinatus, and that of the long portion of the 
biceps; and anteriorly and interiorly it is protected by the ten- 
don of the subscapularis. The inferior part of the articulation 
is deprived of a similar support, and corresponds to the cellular 
substance, the glands, nerves, and blood-vessels that fill the 
axilla. Now, when the elbow is carried upwards and outwards, 
the head of the humerus, by pressing on the inferior side of 
the obicular ligament, may easily lacerate it; but in the mean 
time, the tendon of the long portion of the triceps opposes its 



GF LUXATIONS OF THE OS HUMERI* 24* 

escape precisely at the inferior part of the cavity, and forces it 
to pass out at its inferior and internal part. In this luxation the 
head of the humerus is found placed on the superior and inter- 
nal part of the external costa of the scapula, having before it 
the anterior edge of the subscapularis, and the tendon of the 
long portion of the triceps behind it. The laceration of the cap- 
sular ligament is inseparable from this luxation 5 it could not 
take place without this happening. 

In order that this dislocation may take place, the elbow must 
be moved outwards from the body,* and even a little elevated : 
in this motion of the arm, the head of the humerus slides from 
above downwards, and presses on the internal and inferior part 
of the orbicular ligament. The difficulty we experience hi 
luxating the arm downwards in the dead body, is so great, that 
we may conclude that the weight of the body alone would sel- 
dom luxate it in falls on the elbow, were it not for the co-ope- 
ration of muscular action. In order to elucidate the manner in 
which this luxation is effected, let us suppose a case : A person 
fails from a place somewhat elevated, on his elbow moved out 
from the body ; but, on the very moment that the elbow reach- 
es the ground, the pectoralis major, teres major and latissimus 
dorsi, contract, and draw the arm near the body : now, the con- 
sequence must be, as the elbow is fixed against the ground, 
that the muscles will bring downwards and inwards the head 
of the humerus. This force, co-operating with that of the fall, 
forces the head of the humerus through the ligament, and 
produces a luxation downwards. The humerus represents 
here, as in all its motions, a lever of the third kind ; but its re- 
lations are changed, the force remaining always at the middle* 
the point d'appui, which was in the articulation of the hume- 
rus, is now transferred to the elbow. 

Some authors think, that when the arm is moved out from 
the body, the action of the deltoid muscle alone can produce a 
dislocation of it ; and in support of this opinion they refer to 
the case of a person who luxated his arm in attempting to 
raise a registry-book. 

When the luxation has taken place, the head of the hume- 
rus, placed, as already observed, between the subscapularis 
muscle and the tendon of the long portion of the triceps, fills 

* I have given in the Journal <le Medecine, the history of a luxation 
produced by a Fall on ihe top of the shoulder; but we may easily conceive 
that such cases must be extremely rare, and that fracture of the neck, of 
'.lie humerus ib to he expecred from such- a cause, rather than luxation* 



s 

1\2 OF LUXATIONS Or THE OS HUMERI". 

the hollow of the arm-pit ; the orbicular ligament, torn on Its 
internal side, is stretched over, and covers the glenoid cavity j 
the deltoides and infraspinatus muscles are elongated on account 
of the separation of their points of insertion •, the teres minor 
and subscapularis are neither stretched nor elongated, for if their 
superior fibres experience attention, the inferior are relaxed ; 
the coracobrachial, the biceps and triceps, are elongated, and 
the fore-arm is more or less bent ; the brachial plexus and ax- 
illary vessels are not injured ; the circumflex nerve, which 
turns under the head of the humerus in its course to the deltoid 
muscle, is overstretched, and the injury to which it is exposed 
may destroy its function : a paralysis of the deltoides results ; 
and, consequently, an inability to elevate the arm outwards, is 
sometimes a consequence of an injury done to this nerve in a 
luxation of the humerus. 

The symptoms which mark a luxation of the arm are nu- 
merus, and easy to be distinguished. The affected arm is long- 
er than the other : we convince ourselves of this fact, by un- 
dressing the patient, and examining the height of his elbows. 
The arm loses its vertical position, and inclines obliquely down- 
wards and outwards, and the elbow is very much separated 
from the body if the luxation be recent. When, in the heal- 
thy state, the fingers are moved along the external part of the 
os humeri, an equal resistance is felt along its whole length ; 
but, in a case of luxation, it is only at the middle part that this 
resistance is felt ; on the upper part, the integuments, no long- 
er supported by the superior extremity of the bone, yield to 
the pressure of the fingers. The acromion projects ; an empty 
space is felt under it, in which the head of the humerus should 
be placed } the summit of the shoulder has lost its roundness > 
and a hard tumor, formed by the head of the humerus, is 
found in the axilla. The patient cannot perform the motion 
of circumduction, in which the arm describes a cone, the base 
of which is at the ends of the fingers, and the summit at the 
articulation of the humerus with the scapula j neither can 
he bring his hand to his head by describing a semicircular 
line from without inwards. If we direct him to perform 
this motion, he bends the fore-arm, and stoops his head to- 
wards his hand. It is often unnecessary to attend to all 
these circumstances, as the existence of the luxation may 
be ascertained by a simple inspection of -the arm, but especially 
by the change in its direction. However, we have given an 
ample detail of all its characteristic marks, as it is well attested 
ihat uninformed or inattentive surgeons have sometimes been 



OF LUXATIONS OF THE OS HUMERI. 243 

mistaken in their diagnosis. We have mentioned, in treating 
of fractures of the humerus, the marks by which luxations of 
this bone downwards are distinguished from fractures of its 
neck. 

The prognosis is uncertain ; for though very often no seri- 
ous symptom accompanies affections of this kind, still there may 
be great difficulty in reducing the bone, and a paralysis o£ the 
deltoid muscle may ensue. Professor Boyer has seen three ca- 
ses of this kind. 

The means proposed to effect, the reduction are extremely nu^ 
merous ; and, defective as a great number of them are, it may 
be useful to take a view of them, in order to point out what 
led to their disuse. The most ancient is the amhe of Hippo- 
crates, a machine not used in these times, and scarcely to be 
•met with in the richest cabinets of surgical apparatus. It is 
composed of a piece of wood, rising vertically from a pedestal, 
which is fixed ; with the vertical piece is articulated, after the 
manner of a hinge, an horizontal piece, with a gutter formed 
in it, in which the luxated limb is laid, and secured with lea- 
ther strings. The patient places himself on one side of the 
machine ; his arm is extended in the gutter, and secured j the 
angle formed by the union of the ascending piece and the ho- 
rizontal branch is lodged in his arm-pit, and then the horizon- 
tal branch is depressed. In this W2y extension is made, whilst 
the vertical part makes counter-extension, and its superior part 
tends to force the head of the humerus into ks cavity. But 
there is nothing to fix the scapula, and the compression made 
by the superior part of the vertical portion of the machine 
tends to force the head of the humerus into its cavity before it 
is disengaged by the extension ; besides, it compresses the rnus,- 
cles, stimulates them to contraction, and thus renders the elon- 
gation of them impossible. 

The ladder is attended with the same inconveniences. la 
this process, a ladder, six or seven feet high, is placed vertically, 
and fixed in this situation : the upper step is surrounded by a 
linen cloth •, the patient is elevated by means of a stool, so as to 
be able to pass the diseased arm over this step ; a number of 
assistants take hold of the arm hanging on the opposite side of 
the ladder, and extend it, whilst the weight of the patient, 
from under whom the stool has been taken, makes counter-ex- 
tension, and the step tends, by pushing upwards the head of 
the humerus, to force it into its cavity. This process has this 
additional advantage, that the force cannot be proportioned 
to the resistance, since it is always in proportion to the weight 



£44 0F LUXATIONS OF THE OS HUMERI. 

of the patient. If he is very tall and corpulent, the neck of 
the humerus may be fractured. 

The process by the door has the same disadvantages as the for- 
mer, and differs from it only by placing the upper edge of a 
door, instead of the upper step of a ladder, under the axilla. 
The same objections may be made to the process in which two 
strong men, by placing a stick in the axilla, and putting the 
ends of it on their shoulders, raise the patient from the ground, 
and keep him suspended, whilst a number of assistants draw 
the arm downwards. 

Similar defects are foundin many other machines recommend- 
ed for this purpose; that proposed by J. L. Petit is not exempt 
from them •, and, notwithstanding the engraving and long de- 
scription which this surgeon has given of it, it is impossible to 
understand its mechanism. Independently of the great pres- 
sure which it makes on the muscles, the force with which it 
is difficultly appreciated. 

It has been also proposed to extend the patient on a carpet 
spread on the floor, while the surgeon, extended also, but with 
his feet towards the head of the patient, places his left heel in 
the axilla, and presses with it on the head of the humerus, 
and, at the same time, draws the arm with all his force. But 
the arm being parallel to the trunk, it becomes difficult to dis- 
engage the head of the humerus ; the heel compresses the mus- 
cles, and there is nothing to fix the scapula. 

Lastly, it has been recommended to place the patient and sur- 
geon seated opposite one another, with the hand of the former 
secured between the knees of the latter ; this being done, the 
surgeon inclines backwards, and brings with him the hand 
squeezed between the knees, whilst with his hands he endea- 
vours to restore the head of the humerus. It is easily perceived 
that the operator can, in this situation, exert but very little, 
force: and, if this process has succeeded in some cases, it is 
because the reduction was very easy, and would have been ac- 
complished by any means, even the least rational. 

The method we are now to describe is by much the least ex- 
ceptionable : its effects are not contrary to any of all the rules 
laid down in treating of the general therapeutics of luxations. 

A large piece of old linen, rolled up in a bundle, cr, still bet- 
ter, a broad cushion of oaten chafF, folded on itself, is to be 
placed as high as possible in the hollow of the arm-pit ; the 
bundle ought to be big enough to fill the entire hollow, and to 
reach beyond the borders of it in such a manner as to diminish 
the pressure made on the tendons of the pectoralis major, latis- 



OF LUXATIONS OF THE OS HUMERI. 245 

simus dorsi, and teres major, by counter extension. A sheet 
or table-cloth, folded longitudinally to about four fingers breadth, 
is used for making counter- extension ; the middle of this is ap- 
plied on the cushion, and the ends of it, carried obliquely be- 
fore and behind the breast to the opposite shoulder, are com- 
mitted to assistants. This part of the apparatus fixes the trunk, 
and even the scapula, to a certain degree ; but this bone, un- 
compressed towards the middle of its external border, would 
yield to the extending force, and the reduction would be im- 
practicable, if it were not fixed in the following manner : a 
napkin, folded longitudinally, to about three fingers breadth, 
is applied across the top of the shoulder, and one or two assist- 
ants take the ends of it, which are brought horizontally before 
and behind the breast to the other side of the trunk; and lastly, 
another assistant presses the acromion from above downwards, 
and prevents the folded napkin from moving out of its place, 

Extension is made by assistants, who pull by a napkin, folded 
diagonally, and tied round the wrist of the patient. Every 
thing being thus arranged, and the patient seated, the surge- 
on places himself on the external side of the arm, directs the 
proceedings, attends to the elongation of the muscles, and, 
when he sees them yield to the extending efforts, conducts the 
head of the bone into its cavity. The two hands placed on the 
internal and superior part of the arm are sufficient for this pur- 
pose ; a napkin passed under the patient's arm and round the 
neck of the surgeon would be both embarrassing and useless. 
The assistants employed for making extension draw first in an 
oblique direction downwards and outwards ; but, apprised by 
the surgeon, they bring the arm at the proper time in its natu- 
ral direction, whilst he forces upwards and outwards the head 
of the humerus. That the coaptation may be made with the 
greatest advantage possible, the operator should convert the hu- 
merus into a lever of the third species, the inferior part of which 
is supported against his breast. The effort of the assistants who 
extend the arm is to co-operate with that of the operator, who 
directs all the proceedings. When the muscles are sufficiently* 
elongated, and the head of the bone disengaged, the elbow is 
brought inwards and forwards, in order to give the humerus its 
natural direction. This is to be done without suspending the 
extension, the cessation of which would allow the muscles to 
reassume their power, and bring back the head of the humerus 
to the place from which it had been disengaged. 

When the first attempts at reduction fail, bleedings and warm 
baths are to be had recourse to •, and, after these have had their 



246 OF LUXATIONS OF THE OS HUMERI. 

effect, the patient is to be placed on a strong and firmly fixed 
table, and the operation is to be recommenced. By repeating 
the attempts, the muscles are fatigued, their force is exhausted, 
and the reduction is rendered more easy. If, at the end of 
some days, after repeated endeavours, and inducing debility by 
the usual means, even by the excessive use of spirits and opi- 
um, we are not successful, we advise the patient to call in 0- 
ther practitioners; but in no case or under no circumstances 
are pullies or other extending machines of this kind to be used. 
I have seen in a department distant from the capital, a patient, 
absolutely tortured by the violent means that were employed to 
reduce a luxation of his arm, and yet the reduction was not ac- 
complished. The patient, an adult, strong and robust, was 
stretched on a bench, and held down by a number of men •, 
a band passed round the inferior part of the luxated arm, was 
tied to a vine-press, which was turned by twelve men ; but 
scarcely had they put the machine in motion, when the skin 
of the shoulder and arm-pit cracked in many places ; the la- 
ceration would have been more considerable, or indeed the 
arm would have been torn from the body, if the assistants who 
were employed to hold down the patient had remained deaf 
to his cries. 

Citizen Boyer has seen the same consequences from similar 
attempts to reduce an old luxation of the humerus. The bands 
for making counter-extension were fixed to a post, and exten- 
sion was made by a pulley. The pectoralis major, latissimus 
dorsi, and teres major, were net elongated in the smallest de- 
gree, and the attempt was given up, without accomplishing the 
reduction, though the force employed was so considerable as to 
lacerate the skin, and produce the most exquisite torture. It 
has been supposed that the narrowness of the opening through 
which the head of the humerus has escaped, might resist its re- 
duction ; and in cases where this obstacle is suspected, surgeons 
have directed to move the luxated arm in a/variety of directions, 
in order to make the opening wider by increasing the laceration. 
But, independently of the difficulty of ascertaining the rea- 
lity of this cause, how can the opening through which the 
head of the bone has escaped, be too little at the end of a few 
hours to re-admit it ? Is not the effect of this practice, in cases 
where this obstacle has been supposed, to be attributed to the 
lassitude of the muscles that it produces', rather than to an en- 
largement of the laceration in the orbicular ligament ? 

We have said, in treating of luxations in general, that at 
the end of a month or six weeks, reduction is, if not impossi- 



OF LUXATIONS OF THE OS HUMERI. 247 

ble, at least very difficult ; and we have pointed out the me- 
thod to be pursued when this operation is attempted m these ca- 
ses. 

Luxation of the humerus inwards may be primary or secon- 
dary. If a person fall from a height on his elbow placed out- 
wards and backwards, the action of the muscles co-operates 
with the effects of the fall, and both force out the head of the 
humerus at the anterior and internal part of its cavity, and pro- 
pel it into the fossa subscapularis between the scapula and 
subscapularis muscle. In this luxation, the external edge of 
the subscapularis is moved from the fossa by the head of the 
humerus, which lacerates even the texture of this muscle, 
when the violence has been great, and the luxation effected 
with rapidity. As to secondary luxations in this direction* 
they take place when the head of the humerus deserts the 
part of the scapula on which it was placed in a luxation down- 
Wards, and is drawn by the action of the muscles, parti- 
cularly by that of the pectoralis major, along the fossa subsca- 
pularis, and under the subscapularis muscle to the inferior side 
of the clavicle. 

Some have believed that the head of the humerus might he 
carried upwards towards the clavicle, and be placed between the 
great pectoral muscle and the subscapularis ; but the relations 
of the latter muscle with the internal side of the articulation. 
are such, that it should be turned under the head of the hu- 
merus before a secondary luxation could take place in this di- 
rection. The subscapularis, carried inwards, remains always 
at the internal side of the head of the humerus; and if this 
latter part ascends near to the coracoid process, it can only do 
so by sliding between the subscapularis muscle and the fossa of 
the same name : in that case, the hard and round tumor which 
is felt below the clavicle and before the point of the shoulder* 
is formed by the head of the humerus, covered not only by the 
pectoral is major and minor, but also by the subscapularis. 

In the luxation of the humerus inwards, the arm preserver 
nearly itsnatural length, unless the head of the bone be brought 
secondarily towards the clavicle, in which case it is shortened. 
The elbow is placed outwards from the body, and carried 
backwards ; a bony eminence is felt at the superior and external 
part of the breast, before the point of the shoulder, and below 
the clavicle ; there is no tumour in the axilla •, the point of the 
shoulder is more round, and the acromion is less prominent 
than in luxations downwards \ lastly 3 the motion of circumduc- 
tion is impossible. 



248 OF LUXATIONS OF THE CS HUMERI. 

The prognosis is more unfavourable in this luxation than in 
that downwards ; the straining of the parts has been greater, 
the laceration more considerable, and the reduction is more dif- 
ficult •, it is particularly difficult when the luxation is of a long 
standing, and of the secondary kind. The head of the bone, 
in these circumstances, often grows to the superior part of the 
fossa subscapularis. The process for reducing it is the same as 
that used in the luxation downwards, with this slight difference -. 
the assistants who extend the arm are to pull at first in the di- 
rection of the elbow which was carried backwards, and not 
bring it forwards but at the moment when the head of the bone 
is disengaged from the muscle and the fossa subscapularis. If 
the luxation be secondary, we are first to endeavour to bring 
the head of the humerus downwards into the hollow of the 
arm-pit, and then replace it as in cases of luxation downwards. 

There is no well-attested instance of luxation of the hume- 
rus outwards or backwards, though many authors appear to have 
admitted the possibility of it. It cannot take place secondarily, 
and succeed to a luxation downwards, because the tendon of 
the long portion of the triceps opposes it. Should a fall on 
the elbow placed inwards and forwards produce it primarily, 
the head of the humerus would be carried into the fossa infras- 
pinalisbetween the external part of this fossa and the infraspi- 
pinatus and teres minor muscles. The resistance of the spine 
of the scapula would prevent the humerus from ascending so 
high as to occasion a shortness of the arm ; but the elbow 
would be placed inwards and forwards. The acromion would 
project., especially anteriorly ; an eminence would be felt be- 
hind the shoulder below the spine of the scapula ; the motion 
of the humerus would be painful, and that of circumduction 
impossible. It is to be reduced according to the rules already 
laid down ; but the arm is to be drawn at first inwards and for- 
wards, in order to disengage the head of the bone before bring- 
ing it to its natural direction. 

Whatever may be the kind of luxation, the reduced bone is 
easily kept in its place, by preventing the motion of the arm ; 
and as luxation can take place only when the arm is at some 
distance from the trunk, a return of it will be certainly pre- 
vented by tying the elbow to the side. A bandage carried se- 
veral times round the trunk, and including the elbow, answers 
this purpose. The spica bandage applied to the point of the 
shoulder would not answer so well the proposed end ; its action, 
from being confined to the superior extremity of the humerus, 



OF LUXATIONS OF THI OS HUMERI, 249 

would not prevent the motion of the elbow ; consequently we 
find, that it is now only used to retain emollient and resolvent 
topical applications, which it is sometimes necessary to apply to 
the shoulder. Different symptoms which may accompany or 
succeed luxations of the humerus* such as pain, paralysis of the 
deltoid muscle, or oedema of the arm, may render such topical 
applications necessary. 

If the shoulder be much contused, and the pain considerable, 
emollient cataplasms are to be applied to the pained part ; and 
if the patient be young and strong, some blood is to be taken 
away. When, by this treatment, the pain is diminished, the 
emollients are to be replaced by resolvents, with a view of dis- 
cussing the ecehymosis. In the generality of cases, the pain 
has entirely vanished, and the patient has recovered the entire 
use of his arm at the end of a month. 

The cedema may arise from the compression made by the 
head of the humerus in the axilla on the veins and lymphatic 
vessels, which bring back the fluids of the superior extremity. 
The round figure of the head of the humerus and its polished 
surface render it unfit for making great pressure, so that it slides 
easily over the soft parts, and seldom produces this symptom. 
Paralysis is much more frequently met with, and it would be a 
much more frequent consequence if the brachial plexus and ax- 
illary vessels did not easily escape from the round and slippery 
surface of the head of the humerus. If these nerves are slightly 
compressed by this bony eminence, a numbness and pain are 
felt in the arm, but these symptoms diappear on the reduction 
being accomplished. This is not the case with the paralysis 
produced by the contusion and disorganization of the plexus ; 
it often resists the application of the most powerful remedies ; 
however, the effects of blisters and frictions with irritating sub- 
stances, such as the tincture of cantharides, may be tried. I 
have seen much benefit arise in these cases from burning moxa 
behind the clavicle, and immediately above the brachial plexus. 

The paralysis, as we have mentioned, is sometimes confined 
to the deltoid muscle. It depends then on the contusion and in- 
jury done to the circumflex nerve by the head of the humerus 
which bends it under it. This affection is sometimes very ob- 
stinate, resists the usual remedies, and is followed by a diminu- 
tion of volume in the muscle. 

Lastly, there is an accident which may arise from the efforts 
to reduce a luxation, with which the practitioner ought to be 
made acquainted, in order that he may not be alarmed at its 
32 



2$Q OF LUXATIONS OF THE OS HUMERI. 

taking place. It is generally produced by the violent efforts 
necessary to reduce an old luxation, and it was in a case of this 
kind that it presented itself to Desault. This surgeon, after 
reducing with great difficulty a luxation inwards, which had 
continued for six weeks, perceived a tumour forming rapidly un- 
der the great pectoral muscle, which soon extended to the ax- 
illa, and filled its entire cavity. Desault and his assistants 
thought that an aneurism was produced by the rupture of an 
artery : but their apprehensions were soon removed. It after- 
wards appeared that the tumour was formed, according to the 
opinion of some, by an effusion of venous blood ; according to 
that of others, by air escaping from the lungs ; but the former 
appears by much the most probable, as the tumour disappeared on 
the thirteenth day, and left a large ecchymosis, which was not 
discussed before the twenty-seventh day. 

Anchylosis is never a consequence of luxations of the hume- 
rus, when they are reduced. The motion of the arm, first 
impeded by the pain, becomes daily more free, and is soon 
performed with as much facility as before the luxation had ta- 
ken place. The recovery of the patient is accelerated by mo- 
ving the arm every day as much as the state of the soft parts sur- 
rounding the articulation will admit. It is even rare to find an 
anchylosis in luxations of the arm which have not been reduced. 
The head of the humerus makes a depression in the part of the 
scapula with which it is in contact, and forms a new articulation, 
which allows more or less extensive motion ; but it will be for 
ever impossible to carry the hand semicircularly to the head. 



25* 



CHAPTER X. 



OF LUXATIONS OF THE FORE-ARM. 



THIS chapter will be divided into three sections : in the 
first we will treat of luxations of both bones of the fore- 
arm from the humerus ; in the second we will describe luxation 
of the superior extremity of the radius from the ulna, and in 
the third we will treat of luxations of the inferior extremity of 
the ulna from the radius. 



section j; 



Of Luxations of the Fore-arm from the Humerus* 

Notwithstanding the extent of the surfaces of the articu- 
lation of the radius and ulna with the os humeri, the strength 
of the muscles and ligaments surrounding it, and the mutual 
reception of the eminences which makes it a perfect angular 
ginglymus, a dislocation of these two bones from the extremity 
of the humerus may take place at the same time. They are 
luxated for the most part backwards, sometimes laterally, but 
very rarely anteriorly : the latter luxation cannot take place 
without a fracture of the olecranon. Luxation backwards is 
the most frequent : it is facilitated by the small size of the co- 
ronoid process, which, when the extremity of the humerus is 
forcibly pushed downwards and forwards, may slide behind it, 
and mount up even to the cavity which receives the olecranon 
during the extension of the fore-arm. 

Luxations latterly are much less frequent, and are always in- 
complete. The great extent of the articulating surfaces in their 
transverse direction, the reciprocal union of their inequalities, 



<Z$2 OF LUXATION OF THE FORE-ARM 

and especially the strength of the ligaments and muscles, which 
arising from the internal and external condyles of the inferior 
extremity of the humerus, go to the fore-arm and hand, give 
great strength to the articulation, and render it impossible to 
effect by any violence a complete luxation laterally. 

In the luxation backwards, the radius and ulna may ascend 
more or less behind the humerus ; but the coronoid process of 
the ulna is always carried above the articular pulley, and is 
found lodged in the cavity destined to receive the olecranon. 
The head of the radius is placed behind and above the external 
condyle of the humerus. The annular ligament, which con- 
fines the superior extremity of the radius to the ulna, may be 
lacerated : in which case, even when the bones are reduced, it 
is difficult to keep them in their proper places, as the radius 
tends constantly to separate from the ulna. 

This luxation always takes place from a fall on the hand ; for, 
when we are falling, we are led by a mechanical instinct to bring 
our hands forwards to protect the body. If, in this case, the su- 
perior extremity, instead of resting vertically on the ground, 
be placed obliquely with the hand nearly in a state of supination, 
the repulsion which it receives from the ground will cause the 
two bones of the fore-arm to ascend behind the humerus, 
whilst the weight of the body pressing on the humerus 
directed obliquely downwards, forces its extremity to pass down 
before the coronoid process of the cubitus. 

The fore-arm in this luxation is in a state of demi-flexion, 
and every attempt to extend it occasions smart pains. The si- 
tuation of the olecranon, with respect to the condyles of the 
humerus, is changed. The olecranon, which in the natural 
state is placed on a level with the external condyle, which is 
itself situated lower than the internal, is higher than it. 

This luxation may be mistaken for a fracture of the olecra- 
non, of the head of the radius, or even of the inferior extremity 
of the humerus : such a mistake is attended with very bad con- 
sequences *, for if the reduction be not effected before the end 
of fifteen or twenty days, it is impossible to accomplish it after- 
wards. Such was the case of a student of law, who fell down 
stairs and luxated his fore-arm backwards. The surgeon to 
whom he applied, thought he discovered a fracture of the 
head of the radius, and treated him as if a fracture had really 
taken place j but at the end of twenty days the error was de- 
tected, without a possibility of reducing the luxation. The 
swelling, more or less considerable, which supervenes in twenty- 
four hours after the accident, renders a diagnosis difficult ; the 



FROM TH<E HUMERUS. 2$$ 

the bony prominences are so covered by it, that it is impossi- 
ble to examine their respective situations. Besides, the rubbing 
of the coronoid process and olecranon against the humerus, 
causes a grating noise similar to that in fracture. From these 
circumstances it must appear, that much attention is requisite 
to establish a diagnosis between fracture of the head of the ra- 
dius, and dislocation of the fore-arm backwards. 

Different methods have been proposed to reduce this luxa- 
tion of the fore-arm : some direct to place the elbow of the 
patient on a table covered with many folds of cloth ; while the 
surgeon places his elbow in the bend of the arm, insinuates 
his fingers between these of the patient, and bending his fore- 
arm draws up the hand, and presses at the same time with his 
elbow on the inferior part of the humerus. But the force that 
can be applied in this way is inconsiderable *, besides, the pres- 
sure forces the inferior extremity of the humerus against the 
luxated bones, increasing the friction and the difficulty of reduc- 
tion. The same inconvenience attends the method which con- 
sists in placing the fold of the luxated arm against a bed- post, 
and bending the arm by means of an assistant, while the surgeon 
pushes the olecranon downwards and forwards. 

The following method is by much preferable. The patient 
being firmly seated, an assistant seizes the middle part of the 
humerus, and makes counter extension, while another assistant 
makes extension by drawing by the inferior part of the fore-arm; 
the surgeon, seated on the outside, grasps the elbow with his 
two hands, by applying the four fingers of each hand to the 
anterior part of the humerus, and the thumbs to the posterior, 
with which he presses on the olecranon, in a direction down- 
wards and forwards. This method will be in general successful. 
If the strength of the patient, or the long continuance of the 
luxation, render it necessary to employ a greater force, a fillet 
is to be applied on the wrist to make extension, and a cushion 
is to be placed in the axilla, and the arm and trunk fixed as is 
done in cases of luxation of the humerus. 

When the luxation is reduced, which is known by the noise 
the bones make in reassuming their situation, by the relative 
position of the processes, by the form of the part, and the fa- 
cility of flexion and extension, long compresses moistened with 
a resolvent liquid, are to be applied to the elbow. They should 
be arranged obliquely, so as that their extremities may cross 
one another, and the whole form a figure of 8, which arrange- 
ment will prevent them from falling off. The fore-arm is to 



254 OF LUXATIONS OF THE FORE-ARM 

be neither much bent nor extended. A roller is to be passed 
tightly round the hand and fore-arm, in order to prevent an ef- 
fusion of lymph. The laceration which always takes place, is 
accompanied with more or less inflammatory swelling, which is 
to be combated by blood-lettings, emollient cataplasms, ano- 
dynes, resolvents, &c. 

At the end of seven or eight days, when the inflammatory 
symptoms are nearly gone, the articulation is to be gently mo- 
ved, and the motion is to be increased every day, in order to 
prevent anchylosis, to which it is remarkably disposed. 

In a luxation of the fore-arm backwards, the annular liga- 
ment which confines the head of the radius to the extremity of 
the ulna is sometimes torn, and the radius passes before the cu- 
bitus. In such cases the motions of pronation and supination 
are difficult and painful, though the principal luxation has been 
reduced. The head of the radius may be easily replaced, by 
'pressing it from before backwards, and it is kept in its place by 
adding to the apparatus above described, a compress, which is 
to be applied to the superior and external part of the fore-arm. 
The bandage and compresses are to be taken off" every two or 
three days, and re-applied : this precaution is very necessary, 
on account of the relaxation of the bandages, and the necessity 
of moving the articulation to prevent an anchylosis. 

If the luxation be not soon reduced, it becomes irreducible ; 
the superior extremities of the bones of the fore-arm grow to 
the humerus at its posterior part, and the patient can neither 
bend nor extend his arm. However, in some cases, especially 
in young persons, some motion is acquired in time, the heads 
of the radius and ulna make depressions in the humerus, and 
form for themselves cavities, in which they perform some mo- 
tions, but always imperfectly. 

The luxation forwards should be treated as a fracture of the 
olecranon, with which it would be inevitably accompanied. It 
may be necessary, on account of the great injury done to the 
soft parts, to bleed the patient copiously, and put him on an 
antiphlogistic regimen. 

As to the lateral luxations, either inwards or outwards, they 
are always incomplete, and easily discovered. They are redu- 
ced by drawing the humerus and fore-arm in contrary directions, 
and at the same time pushing the extremity of the humerus 
and the two bones of the fore-arm in opposite directions. The 
extension and counter-extension diminish the friction of the 
surfaces of the articulation, and facilitate their sliding over one 
another. 



FROM THE HUMERUS. 2$$ 

These luxations cannot be produced without considerable vi- 
olence ; but when the bones are reduced, they are easily kept 
in their place. It wiil be sufficient to pass a roller round the 
part, to put the fore-arm in a middle state, neither much bent 
nor extended, and to support it in a sling. But much inflam- 
mation is to be expected, from the injury done to the soft parts. 
In order to prevent it, or at least mitigate it, the patient is to 
be bled two or three times, and put on a low diet, and the ar- 
ticulation is to be covered with emollient cataplasms. It is 
scarcely necessary to repeat that the arm is to be moved as soon 
as the state of the soft parts will admit of it. 



SECTION II. 



Of Luxations of the superior Extremity of the Radius from the Ulna. 

The two bones of the fore-arm, articulated laterally by a 
double ginglymus, may be luxated from one another. But of 
these dislocations, of which the ancients make no mention, 
there is none more frequent than that of the head of the ra- 
dius from the ulna. The superior extremity of the former may 
be forced before or behind the little sigmoid cavity of the ulna, 
destined to lodge a part of its circumference. They may take 
place instantaneously, from a violent and sudden effort, or gra- 
dually ; and on account of this difference, they are divided in- 
to primary and secondary. We will treat first of the primary. 

Though the superior extremity of the radius, in its different 
/notions round the ulna, turns on its own axis, yet different ob- 
servations prove that this extremity of the bone may be dislo- 
cated. The possibility of its luxation forwards, which ought 
to be rarer than that backwards, is easily conceived. The cause 
of the one being more frequent than the other may be this ; 
the motion of supination, which must take place to produce lux- 
ation forwards, is less free and less extensive than that of pro- 
nation, in which the luxation backwards is effected ; besides, 
the little sigmoid cavity in the ulna presents anteriorly on its 
margin a bony prominence, which prevents in some degree the 
head of the radius from passing on that side. 

Many cases of primary luxation of the radius backwards are 
found in the work of Duverney. Citizen Boyer has met 



2$6 OF LUXATTONS OF THE RADIUS. 

with it twice in a child of ten or twelve years of age. I have 
seen a similar affection, in a child of the same age, in conse- 
quence of a fall. In this luxation, the hand is in the state of 
pronation, and cannot be brought to its natural state, which is 
the medium between pronation and supination. The eminence 
formed by the head of the radius, instead of being felt under the 
external condyle of the humerus, is placed behind at the external 
side of the olecranon. A depression is felt at the superior and ex- 
ternal part of the fore-arm. In order to reduce it, the left hand is 
to be placed on the elbow, so as to be able to push with it the 
head of the radius from behind forwards, and the patient's 
hand is to be taken by the other and brought towards supina- 
tion, while the displaced extremity is pushed forwards. The 
noise heard at the moment that the extremity of the radius 
enters the sigmoid cavity, the remission of the pain, the change 
in the shape, and the facility of performing pronation and su- 
pination, indicate that the luxation has been reduced. The 
after-treatment consists in surrounding the part with compresses, 
wet with resolvent liquids, and in covering the entire limb 
with a roller The articulation should be frequently moved, 
but always very gently, as the annular ligament unites with 
difficulty, and only after a long time. 

The secondary luxation of the superior extremity of the 
radius, arises from small efforts often repeated, which, without 
immediately displacing the bone, disposes it to relinquish gra- 
dually the sigmoid cavity. It takes place in young children. 
Nurses generally take children by the hand when they walk, 
to prevent them from falling j and when they are in danger of 
falling, support them by drawing up the arm with the hand in 
an overstretched state of pronation. The same is done some- 
times to put them over a little stream, or even to carry them 
to a certain distance. The straining occasioned in this way, 
produces a dull pain, which each repetition of the practice in- 
creases. The child complains of this pain when the articula- 
tion of the elbow is pressed on. He makes less use of this 
arm than of the other, and if he receives a sweetmeat in the 
hand of this side, he passes it to the other to cbnvey it to his 
mouth. In this state of the disease, it will be only necessary 
to avoid a repetition of the cause, and to apply embrocations 
to the part. If these precautions are neglected, and if the 
practice of raising the child by the arm be persisted in, the 
pain continues and increases 5 a swelling appears in the pained 
joint j the superior extremity of the radius is carried backwards'; 
the motions of the fore-arm are obstructed, and usually, in 



OF LUXATIONS OF THE ULNA. Itf 

scrofulous children, the tumefaction of the joint increases; the 
extremities of the bones become carious ; abscesses form, 
which either on breaking spontaneously, or being artificially 
opened, cause fistulous openings into the joint. Then the dis- 
location of the extremity of the radius is no more the principal 
disease ; this consists of a painful swelling of the soft parts, and 
enlargement and caries of the ends of the bones. In the chap- 
ter on white 9wellings we will give the treatment of it. 



SECTION Ilia 



Of Luxations of the inferior Extremity of the Ulna, 

We give this denomination to the dislocations of the infe- 
rior extremities of the bones of the fore-arm, which other au- 
thors describe under the name of luxations of the inferior ex- 
tremity of the radius. Although this extremity moves on the 
ulna, yet, as the head of the latter evidently escapes from the 
sigmoid cavity of the radius, and as, in considering the affection 
as arising from this dislocation, it is easier to explain the phe- 
nomena of it, we have adopted this name in preference. 

The inferior extremity of the ulna may be luxated anteri- 
orly, or posteriorly, from the inferior extremity of the radius. 

The first of these luxations, of which we have but few exam- 
ples, must be much less frequent than the second, because the 
excessive supination of the hand necessary to produce it is more 
difficult than its pronation. It is well known that it is in the 
state of pronation that the hand performs almost all its motions, 
and fulfils the greater part of the purposes to which it is adapted. 
In this luxation, the head of the radius rolls from before back- 
wards, or from within outwards on the head of the ulna, and 
pushes it forwards; if the luxation take place rapidly, the liga- 
ments between the bones will be torn, and the little head of the 
ulna will be forced before the inferior extremity of the radius. 
In this state, the hand is in a continual state of supination, and 
cannot be brought to that of pronation; a tumour is felt before 
the radius ; there is an empty space where the inferior extremity 
of the cubitus should be; and this bone, instead of being pa- 
rallel with the radius, crosses it obliquely at its inferior part. 
Reduction is easily effected. It is done by pulling the arm, 
33 



258 OF LUXATIONS OF THE ULNA. 

and at the same time turning it a little inwards, whilst the 
head of the ulna is pushed backwards, and the extremity of 
the radius carried forwards, the person who extends the arm 
bringing the hand at the same time to the state of pronation. 
The noise made by the replacing of the bones, the disappear- 
ance of the deformity, and the facility of putting the hand in 
the supine or prone state, shew that the luxation is reduced. 
Compresses wet with resolvent liquids, and a roller passed 
tightly round the fore-arm, are all the apparatus that are ne- 
cessary after the reduction ; the hand is to be kept at rest and 
supported in a sling. This luxation, if neglected, would lead 
in a very short time to the loss of motion in the joint from an 
anchylosis. 

Citizen Boyer has met a remarkable case of luxation of the 
cubitus anteriorly, which is extremely rare. A woman engaged 
in a riot, that took place in a coffee-house near the market- 
place of Saint Germain, was pushed out of the house by a man 
who twisted her hand violently in the supine direction ; she 
felt horrible pain, and cried out that her wrist was breaking, 
and in the moment saw that a deformity supervened. Profes- 
sor Boyer was called in; he found the hand fixed in the supine 
state, the fore-arm bent, and the hand supported before the 
breast. The oblique direction of the inferior extremity of the 
ulna which crossed the radius, was very remarkable. The 
reduction was accomplished only by the fourth attempt. 

The luxation backwards of the inferior extremity of the ul- 
na, described by authors under the name of luxation forwards 
of the inferior extremity of the radius, has been frequently ob- 
served. It is more frequent than the former, because the mo- 
tion of pronation, by which it is occasioned, is more habitual 
than that of supination; and as luxation forwards is produced 
by a violent supination, so that backwards is the result of a 
violent and sudden pronation. Such was the case of the female 
mentioned in Desault's Surgical Journal, who luxated the cubi- 
tus backwards in wringing wet cloths; in doing which, the 
hands are put in the greatest state of pronation possible. The 
hand in this luxation is fixed in the prone state, is incapable of 
supination, and is a little inclined inwards. The ulna crosses 
the radius obliquely, but its little head forms a tumour behind 
the inferior extremity of this bone. It is reduced in the same 
manner as the luxation forwards, with this difference, that the 
hand is to be moved in a contrary direction. If the luxation 
has been neglected, and a swelling of the articulation has su- 



OF LUXATIONS OF THE WRIST. $59 

pervened, no attempt is to be made to effect a reduction until 
the swelling is discussed by means of emollient cataplasms; we 
should not however defer the reduction too long, as it often 
becomes impossible after a very short time. In the latter case, 
the person is not so much disabled in the luxation backwards, 
as in that forwards; the state of pronation being much more 
convenient for the purposes of the hand, than that of supina- 
tion. 



CHAPTER XL 



OF LUXATIONS OF THE HAND, 



SECTION I. 



Of Luxations of the Wrist • 

FOUR kinds of luxations may take place in the articulation 
of the bones of the carpus with the inferior extremities 
of those of the fore-arm, viz. luxation forwards, backwards, 
inwards, and that outwards. But the two first, especially that 
backwards, are the most frequent, because the motions of flex- 
ion and extension are much more extensive than those of ad- 
duction and abduction, and because the extent of the articula- 
ting surfaces is greater from within to the outside, than from 
before backwards; besides, the styloid apophyses of the radius 
and ulna strengthen the external and internal sides of the arti- 
culation, and render dislocation in the transverse direction still 
more difficult. 



26o OF LUXATIONS OJ THE WRIST. 

The articulation of the hand with the fore-arm is remarkable 
in this, that it admits of flexion and extension nearly to the 
same extent; whilst these two motions, in all the other articu- 
lations, have rarely the same latitude, that of flexion being 
always the most considerable. 

Luxation backwards is facilitated by the direction of the con- 
vex articulating surfaces of the scaphoides, semilunaris, and 
pyramidalis, which, inclined more backwards than anteriorly, 
must be more disposed to slide in this direction than in any 
other. It is caused by a fall on the back of the hand while 
much benf, in which case the first range of bones of the wrist 
slides backwards into the oblong cavity of the two bones of the 
fore-arm, extends and lacerates the posterior ligament, and 
forms an eminence behind the ends of the radius and ulna. 
This tumour, the depression at the anterior part of the wrist, 
and the extraordinary flexion of the hand which cannot be ex- 
tended, are the distinguishing marks of this luxation. It is re- 
duced by fixing the fore-arm, and drawing the hand, whilst 
pressure is made on the eminence formed by the displaced car- 
pus to force it back into its cavity. An assistant fixes the arm, 
and the surgeon makes extension and adjusts the bones. Lux- 
ation forwards is occasioned by a fall on the palm of the hands, 
the fingers being extended, and more force being applied to 
the inferior part of the palm than to the superior. It is rarely 
complete; the hand remains painfully extended, and cannot 
be restored to its natural direction without some difficulty. 
The numerous tendons which pass before the wrist, and the 
annular ligament which confines them, being pushed forwards, 
render it so difficult to discover the eminence formed by the 
bones of the wrist before the ends of those of the fore-arm, 
that this affection may be easily mistaken for a sprain. Conse- 
quently, in all doubtful cases, we should proceed as if the lux- 
ation had really taken place, and bring the hand into its proper 
direction. 

Luxations backwards, but especially those forwards, are al- 
ways accompanied with a more or less considerable laceration 
of the ligaments, and are followed by an inflammatory swelling 
difficult to subdue; hence the full use of the wrist is not re- 
covered for a considerable time. When the bones are reduced, 
the remainder of the treatment is the same as in cases of sprain: 
refrigerents and repellents are to be first used, and then emol- 
lients and resolvents. The patient must not fatigue the hand 



OF THE BONES OF THE CARPUS, &C. %6\ 

much, even for some time after complete recovery, lest he ex- 
cite inflammation, and lay the foundation of a white swelling. 
Luxations inwards, and those outwards, are never complete. 
The laceration of the ligaments, a tumour at the internal or ex- 
ternal side of the joint, and distortion of the hand, are the 
concomitant symptoms of these luxations, and mark them out 
sufficiently. They are reduced by making gentle extension, 
and causing the two surfaces of the joint to slide on one ano- 
ther in a direction contrary to what they took in luxating, and 
by bringing the hand into its natural situation. The dagger of 
these luxations depends less on the dislocation than on the 
straining and laceration of the soft parts, which are always fol- 
lowed by more or less tumefaction, a symptom difficult to sub- 
due, and often the cause of anchylosis, or even of caries. 



SECTION II. 



Of Luxations of the Bones of the Carpus and Metacarpus. 

The motions of the bones of the carpus in their articulations 
with one another are so limited, and their connexion is so 
strong, that a dislocation of them appears entirely impossible. 
However, the head of the os magnum, which is received in a 
deep cavity formed for it by the scaphoides and semilunaris, 
may escape from this cavity, be luxated backwards by too great 
a flexion of the bones of the first range on those of the second, 
and form a tumour on the superior part of the back of the 
hand. I have lately seen a remarkable case of this luxation. 
Mrs. B. in a labour pain, seized violently the edge of her mat- 
tress, and squeezed it forcibly, turning her wrist forwards; 
she instantly heard a slight crack, and felt some pain, to which 
her other sufferings did not allow her to attend. Fifteen days 
afterwards, happily delivered, and recovered by. the care of 
Professor Baudelocque, she shewed her left hand to this cele- 
brated accoucheur, and expressed her disquietude about the 
tumour which appeared on it, especially when much bent. I 
was called to visit this lady. I found that this hard circum- 
scribed tumour, which disappeared almost totally by extending 
the hand, was formed by the head of the os magnum luxated 
backwards j I replaced it entirely by extending, the hand, and 



262 OF LUXATIONS OF THE FINGERS. 

making gentle pressure on it. As the affection did not impede 
the motion of the part, as the tumour disappeared on extend- 
ing the hand, and as it would have been even little apparent 
in any state of the hand, had Mrs. B. been more in flesh, I 
advised her not to be uneasy about it, and to apply no re- 
medy to it. Chopart observed a similar dislocation in a butcher. 
Professor Boyer's practice has presented him also a case of it. 

As to the bones of the metacarpus, they are connected so 
closely and strongly, and support one another so firmly in ef- 
forts made against the palm of the hand, that they are never 
luxated. The ligaments of their articulations may, however, 
be overstretched and torn, and a painful diastasis produced, 
which will require the use of emollients and resolvents, with 
immobility of the hand as long as the affection continues. 

Notwithstanding the mobility of the articulation of the tra- 
pezium with the first bone of the metacarpus, the latter is lux- 
ated but very rarely. Efforts made on the thumb, which is 
supported by this bone, would produce rather a luxation of the 
first phalanx, than that of the metacarpal bone. The second 
and third bones are so firmly articulated with one another, and 
with the bones of the second row of the carpus, that they are 
not susceptible of any luxation whatever. As to the fourth and 
fifth, a little more moveable, and supported by the os unci- 
forme, their articulations are more susceptible of sprains than 
true Luxations. 



SECTION III. 



Of Luxations of the Fingers. 

The first phalanges may be luxated backwards at their ar- 
ticulations with the bones of the metacarpus. A luxation of 
them forwards would be very difficult, if not altogether impos- 
sible, on account of the disposition of the articulating surfaces 
of the metacarpal bones, which are much elongated forwards, 
and allow a great extent of motion to the phalanges in this 
direction, without losing contact with them; and on account 
of the resistance made by the palm of the hand, which would 
restrain the flexion carried beyond what the inclination of the 
articulating surfaces would admit of. Luxations inwards can 



OF LUXATIONS OF THE FINGERS. 263 

take place only in the first phalanges of the thumb and little 
finger; as to that outwards, the first phalanx of the thumb alone 
is susceptible of it. This phalanx is also the most exposed to 
luxations backwards. When a violent effort is made on the 
thumb from before backwards, its first phalanx slips behind 
the head of the first metacarpal bone, and remains extended, 
while the second is bent, its flexor-muscle being thrown into 
action by the irritation. The distortion of the thumb, the im- 
possibility of bending the first phalanx, and the pain, render 
this luxation sufficiently evident. 

The more violent the effort necessary to produce these lux- 
ations, the more grievous are their consequences. In some per- 
sons in whom the ligaments are excessively relaxed, they pro- 
duce no inconvenience. In such, the first phalanx of the thumb 
may be luxated at will ; but then it is as easily reduced as dis- 
placed. 

These luxations should be quickly reduced, for, 2it the end 
of eight or ten days, they are irreducible. Desault, i n a case of 
this kind, proposed making an incision behind the superior 
extremity of the phalanx, and by means of it to introduce a 
spatula, in order to push the phalanx into its place ; but the 
patient, frightened at the operation, would not submit to it. 
Citizen Boyer has also observed in a hair-dresser, a luxation 
backwards irreducible from having continued too long. 

The reduction is not as easy as one might imagine. The num- 
ber and force of the muscles which are inserted in to the first 
phalanx of the thumb, and the little hold we can t ake of this 
part in order to make extension, render the reduction difficult. 
Luxations of the first phalanges of the thumb and little finger 
inwards, that of the thumb outwards, and luxations of the first 
phalanges of the other fingers backwards, are all reduced by 
making extension on the inferior extremity of the a .ffected fin- 
ger, round which a fillet is to be passed if there be o ccasion for 
much force. The wrist is fixed by an assistant, l.vho makes 
counter-extension, and the surgeon replaces the bone. The 
first and second phalanges are also susceptible of luxzition back- 
wards, which only differs from the former by being more easily 
reduced. After the reduction is accomplished, a roller is put 
round the finger to prevent a return of the luxation, 



i&j 



CHAPTER XII 



OF LUXATIONS OF THE FEMUR. 

THE articulation of the femur with the bones of the pelvis 
is so strong and well secured, that luxations of it are not 
frequent j thus they are much rarer than those of the humerus, 
yet they are described by all authors, ancient and modern . 
But I am disposed to think that practitioners have often con- 
founded primary luxations of the femur with fractures of the 
neck of this bone, which are much more common. 

These luxations may take place upwards and outwards on the 
external face of the os ilium, upwards and forwards on the 
body of the os pubis, downwards and inwards on the foramen 
ovale, and downwards and outwards on the os ischium. Hence 
their division, generally admitted, into four well-marked spe- 
cies. 

Luxation- upwards and outwards, and that downwards and 
inwards, are the most frequent ; and it is not easy to ascertain 
which of these two takes place oftenest. No anatomical reason 
can be given for the frequency of the first* ; the edge of the 
acetabulum projects more at the superior and exterior parts 
than at any other ; the orbicular ligament, which is very thick 
at this place, and the interior ligament of the articulation, 
which must be previously ruptured, oppose the dislocation in 
this direction. There is little, on the contrary, to oppose the 
luxation downwards on the foramen ovale. The inferior and 
internal part of the circumference of the cavity, the place by 
which the bone escapes in this species cf luxation, presents a 
deep notch formed into a hole by a ligament, under which the 
vessels of the articulation enter. The orbicular ligament is thin- 
ner here than at any ether place; the motion cf abduction, in 
which this luxation takes place, is more extensive than that of 

* Except ths disposition of the head of the femur, the articulating part 
of which, covered with cartilage, is continued farther upwaxis and out- 
ward?, than « ownwards and inward?. 



OP LUXATIONS OF THE FEMUR. l6 $ 

adduction; and lastly, the round ligament within the articula- 
tion does not oppose it, as it may take place without its being 
ruptured. 

Luxation upwards and forwards is very rare •, that down- 
wards and backwards is still more so; and, perhaps as shall be 
observed farther on, never occurs but secondarily. 

When, by a fall from a place more or less elevated, on the 
soles of the feet, or on the knees, the thigh is pushed for- 
wards and inwards, the head of the femur, forced towards the 
superior and external part of the acetabulum, breaks the inter- 
nal and orbicular ligaments, escapes through the laceration in 
the latter, and ascends on the external face of the os ilium ; 
but as the part of the os ilium immediately above and at the 
external side of the cavity, is very convex, the head of the 
femur soon abandons its first position, and slides backwards 
and upwards into the external fossa of the os ilium, following 
the inclination of the plane towards this fossa, and obeying 
the action of the glutsei muscles which draws it in this direc- 
tion. The head Of the femur, in ascending thus on the exter- 
nal face of the os ilium, pushes upwards the gluteus minimus, 
which forms a sort of cap for it ; and the gluteus maximus 
and medius are relaxed by the approximation of the points 
jnto which they are inserted. The pyriformis is nearly in its 
natural state, the gemini, obturatores, and quadratus femoris, 
are a little elongated. The psoas magnus and iliacus internus 
are relaxed, as are also the other muscles inserted into the tro- 
chanter minor. If to this description it be added, that the or- 
bicular ligament, torn at its superior part, is stretched over 
the acetabulum and covers it, an exact idea may be formed of 
the change occasioned in the surrounding parts by this luxation 
of the femur. 

The affected thigh is shorter than the sound one : it is a lit- 
tle bent, and carried inwards. The knee inclines more for- 
wards and inwards than the opposite one ; the leg and thigh 
are turned inwards, and the foot points in this direction. The 
trochanter major is brought nearer the anterior and superior 
spinous process of the os ilium, and is at the same time ele- 
vated and carried a little forwards ; the latter circumstance 
may be considered as the necessary consequence of the rotation 
inwards of the thigh. The natural length of the limb cannot 
be restored without reducing the luxation ; the foot cannot be 
turned outwards, and any attempt to do so causes pain ; but 
the inclination of the foot inwards may be increased. If the pa- 

34 



266 OF LUXATIONS OF THE FEMUR. 

tient endeavours to walk, he extends the foot to put the top of 
of it on the ground ; and though the heel is raised, he is still 
lame ; for the diseased limb remains always shorter than the 
other, and the pain occasioned by the attempt to walk ren- 
ders progression still more difficult. 

Luxation of the femur upwards and outwards has nothing 
in common with the fracture of the neck of this bone but the 
shortness of the limb. The easy rotation of the member 
outwards and inwards, &c. &c. preclude all possibility of con- 
founding them, unless the surgeon be remarkably inattentive. 

It is difficult to assign the cause of the foot and remainder of 
the limb being turned inwards in this luxation. It may be esta- 
blished as a general rule, that luxated members always take a 
direction determined by the elongation of the muscles of the 
side opposite that to which the luxated bone is carried : thus in 
luxation of the arm downwards and inwards, the deltoides and 
infraspinatus muscles, lengthened by the separation of their 
points of insertion, move the elbow out from the body, and 
give the arm an oblique direction. In this case, the obtura- 
tores, gemini, and quadratus femoris, being elongated, the 
point of the foot ought to be turned outwards. This pheno- 
menon depends perhaps on the external portion of the orbicu- 
lar ligament which comes from the anterior and inferior spine 
of the os ilium ; this portion, which is very thick, being 
elongated in the luxation outwards, draws the great trochanter 
forwards, and consequently turns inwards the entire limb. 

♦The difficulty of reducing luxations of the thigh, from the 
strength and number of its muscles, renders every dislocation 
of which it is susceptible very distressing. The laceration and 
injury done to the soft parts are nearly as considerable as in 
dislocations of the ginglymoidal articulations. 

To effect the reduction, the patient is extended on a table 
firmly fixed, and covered with a mattress which is to be tied 
to it j a sheet folded longitudinally is applied to the groin of the 
sound side, in order to make counter-extension. The middle 
part is applied against the superior and internal part of the 
thigh, and the two ends passed before and behind the pelvis, 
cross on the hip, and are held by a sufficient number of assist- 
ants. By this means the trunk is fixed, but there is nothing 
to prevent the pelvis from yielding to the extending force. To 
answer this purpose, another sheet folded in a similar manner 
is placed transversely on the spine of the os ilium, and its ends 
are brought horizontally before and behind the abdomen to- 
wards the hip of the opposite side, where they are held by as- 



OF LUXATIONS OF THE FEMUR; 267 

slstants. This apparatus, similar to thfat placed on the point 
of the shoulder in a luxation of the arm, answers the same 
purposes, as it presses only on the superior part of the glutseus 
maximus and medius, and does not stimulate them to contract. 
The extending force is to be applied to the inferior part of the 
leg, in order to have it as far as possible from the parts which 
resist the return of the head of the femur. The number of 
assistants for making extension and counter extension is to be 
proportioned to the exigencies of the circumstances and the 
power of the muscles. The surgeon, placed at the external 
side of the limb, presses on the great trochanter, and when 
the head of the bone has been brought on a level with the 
acetabulum, he endeavours to force it into it. 

The disappearance of all the symptoms, and especially the 
noise made by the head of the femur on re-entering its cavity, 
indicate the success of the operation. This success is seldom 
obtained without having previously made several fruitless en- 
deavours, whether from not employing sufficient force to make 
extension and counter-extension, or from a spasmodic contrac- 
tion of the muscles obstinately resisting the reduction. 

When the bone is reduced, it is prevented from leaving its 
place by bringing the thighs together by means of a bandage 
placed above the knees. In the generality of cases it will be 
adviseable to take some blood from the patient, and confine 
him for a few days after the accident to a very low diet j and 
in all cases the hip is to be covered with emollient and resol- 
vent applications, which may be kept on by means of the spica 
bandage for the groin. This bandage is well adapted to this 
use, but is not at all fit for keeping the luxated bone in its pro- 
per place, as its action is made too near the centre of motion. 
The patient should be particularly directed not to walk too 
Boon, nor at any time to fatigue too much the affected joint. 
It remains always weaker than the other ; the round ligament 
never unites completely, if even its reunion be possible. When 
the limb has not been left at rest for a sufficient length of time, 
(twenty days at least), the pain can never be said to have en- ■ 
tirely disappeared ; it is revived by the slightest effort, and at 
length becomes permanent. The patient, however, does not 
complain much of the pain, but it is more than probable that 
it is occasioned by a swelling of the cartilages and synovial 
glands of the articulation, the direful forerunner of spontane- 
ous luxation of the femur, and of caries of the bones forming 
the acetabulums. 



l6S OF LUXATIONS OF THE FEMUR, 

Luxation of the thigh downwards and inwards, or into the 
foramen ovale, is nearly as frequent as that just described; it is 
favoured, as we have said, by the great extent of the motion 
of abduction of the thigh; by the notch at the inferior and in- 
ternal part of the acetabulum; by the weakness of the orbicu- 
lar ligament at this side ; and lastly by the situation of the round 
ligament, the rupture of which is not a necessary consequence 
of it. It is occasioned by a fall on the feet or knees conside- 
rably separated from one another. The head of the femur 
slides from without inwards on the bottom of the acetabulum, 
and comes against the inferior and internal portion of the or- 
bicular ligament, which it lacerates, and passes on to the fora- 
men ovale between the ligament and the obturator externus. 

In this species of the luxations of the femur, the state of the 
soft parts surrounding the articulation is as follows : the glutaei, 
gemini, obturatores, quadratus femoris, psoas magnus, and 
iliacus internus, are elongated by the separation of their points 
of insertion. The rotation of the limb outwards is produced 
by the elongation of these muscles. The adductors, elongated, 
form at the interior part of the thigh a tense cord, which is 
felt from the pubis to below the middle of the thigh. 

The affected thigh is longer than the sound one ; the head 
of the femur being placed lower than the acetabulum, the 
great trochanter is removed to a greater distance from the an- 
terior and superior spinous process of the os ilium, and the 
thigh is flattened in consequence of the elongation of the mus- 
cles. The adductors, extended obliquely from the pubis to 
the femur, form a cord which elevates the skin of the inter- 
nal part of the thigh. A hard round tumour is felt at the in- 
ner and superior part of the thigh, formed by the head of the 
femur, which elevates the soft parts situated before the foramen 
ovale. The leg is slightly bent ; the knee and foot turned 
outwards, eannot be brought back to their proper direction. If 
the patient attempt to walk a few steps, he makes a semicircu- 
lar motion with the foot, and places at once the entire sole on 
the ground; and though he keep the knee bent, still the limb 
is too long, and occasions lameness. The mode of progression 
of persons whose thigh is luxated in this direction may be com- 
pared to that of a mower : the elongated extremity, like the 
leg which the mower keeps forwards, describes a semicircular 
motion outwards. 

All these symptoms taken together form a combination too 
striking to admit of error in our diagnosis, or to allow us to 



OF LUXATIONS OF THE FEMUR. 0.6$ 

confound this luxation with any other, or even with fracture 
of the neck of the femur. 

The prognosis is somewhat less unfavourable in this than in 
luxation upwards and outwards. The muscles, which might 
oppose the reduction, being all elongated by the very circum- 
stance of the luxation itself, render the reduction easier; besides, 
the contusion of the soft parts is less considerable, and thef 
round ligament is stretched, but not broken. It is reduced in 
the same manner as the other, except that the extension is to 
be made at first downwards and outwards, before bringing the 
limb to its natural direction. 

Luxation upwards and forwards is much rarer than the pre- 
ceding, and more than one practioner has described it rather 
as possible than as having absolutely taken place. It has been 
also called luxation on the pubis, though it may be reasonably 
presumed that the head of the femur is removed so far from 
the acetabulum but in very few cases, and that it only advances 
near the ilio-pectinseal eminence. Desault met a luxation of 
this kind in a porter of the flour-market: his foot slipped, and 
the leg and thigh were carried backwards, whilst a heavy bur- 
den was placed on his shoulders. His body was bent back- 
wards, and the head of the femur, directed forwards and up- 
wards, burst its capsule and triangular ligament, and passed 
under the crural arch into the fold of the groin, where it was 
easily felt through the integuments. 

The whole extremity is turned outwards in this luxation: it 
is also shortened. The great trochanter, brought nearer the 
anterior and superior spinous process of the os ilium, is placed 
before that eminence; that part into which the psoas and ilia- 
cus muscles are inserted is raised up, and a tumour is formed 
by the head of the femur in the fold of the groin, which com- 
presses more or less the crural nerves placed at the external side 
of the vessels of this name, and occasions dull pains, with 
numbness and even paralysis, when the contusion has been very- 
great; the knee, turned outwards, is also carried backwards- 
This symptom is particularly remarkable shortly after the acci- 
dent has taken place; for if the dislocation has continued some 
days, the thigh may reassume its natural direction, and per- 
form even gentle rotatory motions inwards, the direction out- 
wards still continuing. It is proper to remark, with respect to 
the tumour formed by the head of the femur in the groin, that 
the psoas and iliacus muscles may, in fractures of the femur 
immediately under the little trochanter, bring forwards the su- 



Cl"/o of luxations of the femur. 

perior portion of this bone, cause it to project in the groin, and 
form an eminence there which might impose on us, if we were 
not apprized of the possibility of such an event taking place. 

This luxation is particularly dangerous, as it requires a com- 
bination of violent efforts to produce it, and as it necessarily 
must be accompanied with great contusion and lacerations. 
Nevertheless, in the case treated by Desault, the reduction, 
though difficult, was not followed by any serious accident; and 
the patient, at the end of fifteen days, had almost entirely re- 
covered the strength and use of his limb. 

The process for reducing it does not differ from that pointed 
out for the others. 

Luxation of the femur downwards and backwards may, like? 
that of the humerus inwards and forwards, be either primary 
or secondary. It is primary, when, in consequence of some 
effort, the head of the femur is forced from the acetabulum at 
its inferior and posterior part, and is placed at the junction of 
the os ilium and ischium; it is secondary, when it succeeds to 
the luxation upwards and outwards, the head of the femur, 
which was placed at first in the external iliac fossa sliding down- 
wards and backwards, its passage in this direction being fa- 
voured by the bending of the thigh on the pelvis. 

In these two cases, the head of the femur rests against that 
part of the ossa innominata where the os ilium and ischium 
join. The muscles which cover the posterior part of the arti- 
culation, such as the pyriformis, gemini, obturatores, and qua- 
dratus femoris, are raised up and stretched; .the psoas magnus 
and illiacus internus are in a great state of tension, and this 
explains the turning of the limb outwards, When this luxa- 
tion is primary, the extremity is lengthened; a hard tumour is 
felt at the posterior and inferior part of the thigh; the great 
trochanter, by descending, is removed farther from the spine 
of the os ilium, and the knee and sole of the foot are turned 
outwards; but if it be secondary, the thigh is much bent against 
the pelvis; the knee and sole of the foot are turned inwards, 
because the primary luxation has been upwards and outwards. 
Secondary luxation in this direction is much more frequent 
than the primary: in reducing it, the same rules are to be ob- 
served as in other species of luxations. 

Whatever may be the species of luxation, we should always 
be certain that it is perfectly reduced before leaving the patient. 
To ascertain this, we ought to move the thigh in various di- 



OF SPONTANEOUS LUXATIONS OF THE FEMUR. 2J L 

yections, taking care at the same time to omit that motion 
which might reproduce the luxation. 

When a luxation of the femur upwards and outwards has 
not been reduced, the thigh remains short, and becomes shorter 
every day, until the head of the femur has made for itself a 
kind of articular cavity in the surface of the external iliac fossa. 
The acetabulum lessens in size, or is entirely obliterated. The 
glutaeus minimus is emaciated, and serves as an orbicular liga- 
ment to the new articulation. The head of the femur loses its 
spherical figure, is forced backwards, and its neck becomes 
shorter; the person is lame, and walks on the point of the 
foot. If the luxation is downwards and inwards, the foramen 
ovale becomes the new articulating cavity; the obturator ex- 
ternus, raised and pushed inwards by the head of the femur, 
becomes emaciated and ligamentous, and it and the glutaeus 
minimus even sometimes ossify. The lameness arises in this 
case from the excess of length of the diseased limb, which al- 
ways diminishes in size, in consequence of the muscles not 
being sufficiently exercised, or their action being impeded. 



r»'fi»-- ■ijiiTTTilfc nilfHil il 



CHAPTER XIII. 



OF SPONTANEOUS LUXATIONS OF THE FEMUR. 

IT is not, perhaps, without transgressing the rules of noso- 
logy, that these affections, which arise from a swelling or 
caries of the ends of the bones, have been ranked among the 
luxations of the femur. The dislocation, by some called spon- 
taneous, by others secondary, is in fact but the symptom of a 
more grievous affection which always precedes it, and against 
which our treatment should be principally directed. The 
names spontaneous and secondary are well applied to it; the 
£rst, because it often appears to come of itself without any 



272 OF SPONTANEOUS LUXATIONS OF THE FEMUR, 

apparent cause; the second, because it is the consequence of 
another disease. This luxation, though much more common 
than the primary, has been unknown from the time of Hippo- 
crates, who describes it by the name of disease of the hips 
(morbus coxarum) in two of his Aphorisms, to that of J. L. 
Petit; who, though fye mistook its etiology, has nevertheless 
given a very exact description of it in the Memoirs of the Aca- 
demy of Sciences for the year 1722. 

Two principal varieties of secondary luxations are pointed 
out. In the one, the dislocation is occasioned by the swelling 
of the cartilages which line the acetabulum and cover the head 
of the femur, and by the enlargement of the cluster of glands 
in the interior of the articulation, and which have been a long 
time considered as destined for the secretion of synovia. In 
the other, it arises from caries of the circumference of the 
acetabulum or head of the femur. The same causes may occa- 
sion both varieties; they are either external or internal. 

It is only lately that surgeons have admitted the possibility of 
secondary luxation of the femur from an external cause. It 
was generally believed that it could be produced only by internal 
causes, which, in fact, are the most frequent. But it is now 
clearly ascertained, that contusion of the cartilages and seba- 
ceous cluster of glands of the joint from a fall on the feet, 
knees, or great trochanter, may occasion an inflammation and 
swelling of these parts, by which the head of the femur will 
be expelled from its cavity. 

From whatever cause it arises, its most ordinary course is 
this: the cartilages and sebaceous glands, irritated by the ex- 
ternal violence, or by a scrofulous, venereal, or scorbutic taint, 
become swelled; the cartilages grow soft, and degenerate into 
a greyish substance like lard; their sensibility increases, and 
pains, at first dull and slight, but soon acute and deep-seated, 
are felt in the diseased joint. The head of the femur, pushed 
outwards by the tumefaction, is gradually expelled from its. 
cavity; and when it is on a level with the margin of the ace- 
tabulum, it is drawn upwards and outwards on the external 
iliac fossa, by the giutsei muscles, and but very rarely down- 
wards and, inwards on the foramen magnum. 

If, on the commencement of the pains, the patient be ex- 
tended on a plane, and the two superior and anterior spines, 
of the ossa ilia put in a horizontal line, it will be found, on ex- 
amining the affected limb, and comparing its length with the 
sound one, that it is somewhat longer than the other. This 



OF SPONTANEOUS LUXATIONS OF TH2 FEMUR. 273 

elongation increases as the disease advances, and is never so 
considerable as just at the period when the head of the femur, 
on a level with the edge of the acetabulum, is about to pass 
over it. At this moment, the luxation being complete, the 
head of the femur is carried away by the action of the mus- 
cles, and the limb is on a sudden shortened by several inches, 
except in the very rare cases in which the bone is carried down- 
wards and inwards on the foramen ovale. Sharp pains are felt 
during the whole course of the disease; they may arise from 
the affection of the cartilages, or from the straining of the or- 
bicular ligament. They have this very striking peculiarity, that 
the patient complains of them more in his knee than in his hip, 
which in the beginning of the disease might lead into error. 

When the luxation has taken place, the extremity is much 
shortened} the knee and point of the foot are turned inwards; 
the great trochanter is brought nearer the spine of the os ilium; 
the leg is bent; in fact, all the symptoms of primary luxation 
upwards and outwards aire evident. The part over the articu- 
lation swells and grows round; the skin is soon put on the 
stretch; the cellular substance swells and becomes thick, and 
the tumour puts on the appearance of a white swelling; in some 
time, a softness is felt at different points, which correspond to 
so many abscesses; these burst, and their openings degenerate 
into fistulse. A matter, at first serous, and without smell, flows 
from them; but its qualities are soon changed by the contact 
of the air, it becomes acrid, irritating, and so fetid, that the 
patient and those near him can scarcely bear the smell of it : 
this matter, taken into the system by absorption, produces 
hectic fever, marasmus, colliquative diarrhoea, and death. 

On opening the body, the acetabulum is found filled by its 
cartilage, which is converted into a soft greyish substance; the 
sebaceous glands of the joint are also swelled; the substance of 
the head of the femur is altered, and its shape is more or less 
changed according to the continuance of the disease; collections 
of fetid pus are found in the interstices of the muscles, which 
are discoloured and diminished in size; and the os innomina- 
tum and the head of the femur are frequently carious. 

Such is the exact history of the first variety of the disease. 
The progress of its symptoms is somewhat different from what 
is observed in that occasioned by caries; different appearances 
are also found by examination after death. 

In the second variety, the pains are at first acute, and ac- 
companied with swelling of the hip: considerable abscesses form 



274 OF SPONTANEOUS LUXATIONS OF THE FEMUR. 

in this part, which soon burst; a matter, at first inodorous, 
flows abundantly from them, but in a little time it is vitiated 
by the contact of the air, and the openings through which it 
passes degenerate into fistulas. 

The extremity, which was not sensibly elongated, becomes 
suddenly shortened;* the head of the femur mounts up to the 
external iliac fossa; and the patient, exhausted by the copious 
suppurations and hectic fever, is generally carried off. On 
opening the joint, it is found that the edge of the acetabulum 
has been destroyed to a greater or less degree by caries, that 
the cavity has been nearly effaced, and that the head of the 
femur has participated in the disease. 

Both the varieties which we have just described may be in- 
duced even in a person enjoying good health and of a robust 
constitution, by a quick commotion of the hip, as happens 
from making a false step, -by a fall on the sole of the feet, on 
the knees, or even on the great trochanter. A much less de- 
gree of the cause will produce them, if the patient labour un- 
der a scrofulous, venereal, or scorbutic taint. Scrofula has- 
been so frequently the cause of them, that it has been supposed 
that they never originated from any other; but though it may 
be the most frequent cause, still cases are met in which its ex- 
istence could not be suspected. 

It may be objected by those who believe that an internal 
cause is absolutely necessary to produce the disease, that the 
contusion of the parts about the joint acts only as an occasional 
cause; that in luxations supposed to be produced by a fall on 
the great trochanter, the injury, by determining to the articu- 
lation, the principle which vitiates the humours, only developes 
a disease, the germ of which was contained in the constitu- 
tion. 

J. L. Petit, to whom we are indebted for the first accurate 
description of spontaneous luxations of the femur, gives the 
following explanation of the manner in which they take place. 

" By a fall on the great trochanter, the head of the femur 
" is violently forced against the sides of the acetabulum; and 
« as it fills exactly the cavity, the cartilages, synoval glands, 
« and round ligaments, must receive a violent commotion, 

* Sometimes a caries of the acetabulum is not followed by luxation of 
the thigh. Citizen Boyer met a case of this kind, in which the bottom of 
the cavity only was affected; the edges were sound. The pus made its 
way into the pelvis, and formed an abscess in the groin, which burst, and 
left a fistulous opening. 



OF SPONTANEOUS LUXATIONS OF THE FEMUR. 275 

<* which will occasion obstruction, inflammation, and a depo- 
« sition of matter: the synovia, especially, will be accumulated 
« in the cavity of the articulation; the capsule will be distended 
** by it, and the head of the femur gradually expelled until it 
« is entirely luxated." A little reflection will shew the futility 
of this explanation: admitting even that the secretion of syno- 
via was increased by the contusion, without any increase of the 
absorption of it, which is always proportionate to its secretion, 
and that this fluid, accumulated between the neck of the femur 
and orbicular ligament, distended this latter, still a dislocation 
would not take place ; a dropsy of the joint would be the con- 
sequence; for the liquid could not expel a hard resisting body 
such as the head of the femur; and if the synovia accumulated 
between the neck of the femur and the ligament should become 
thick, it would tend more to confine the bone to its cavity than 
to displace it. Petit knew very well that there was a dispro- 
portion between the cavity and the head of the femur; but he 
was mistaken as to the cause of this disproportion, and as to 
the nature of the substance which filled the cavity, and ex- 
pelled the head of the femur. 

The prognosis in these luxations is always unfavourable; it 
is, however, more or less so, according to the age and consti- 
tution of the patient, the species of luxation, its continuance, 
and the cause which has produced it. If the patient be young 
and strong, the affection recent, and accompanied only by dull 
pains and inconsiderable elongation of the extremity, if there 
be no internal taint, and if the cause has been external, the 
danger is much less than if the patient were weak and exhaust- 
ed, the disease of a long standing, and complicated with fistula, 
&c. &c. The prognosis is still more unfavourable when the 
luxation takes place downwards and inwards, the head of the 
femur being placed in the foramen ovale, and the extremity 
elongated. This species of luxation is fortunately very rare; 
the lameness in it, arising from the elongation of the limb, is 
much more troublesome than that arising from the shortness 
of it. 

The principal object in the treatment of this disease, is to 
prevent the spontaneous luxation. If this once takes place, 
the danger increases, and the patient may consider himself 
happy if the head of the femur attaches itself to the portion of 
the os innominatum against which it bears, or, making a de- 
pression, forms a new articulation. Whenever, in consequence 
of a fall on the feet, knees, or great trochanter, a person feels, 



2/(5 QF SPONTANEOUS LUXATIONS OF THE FEMUR. 

in walking, dull pains in the hip, or knee, he should be di- 
rected to keep the limb in the most perfect repose, until they 
entirely disappear. Unfortunately, there are few patients who 
will confine themselves to bed for a complaint apparently so 
trifling, or submit to the bleedings and strict regimen necessary 
in such a case. At the same time that means such as these are 
used, emollients and resolvents may be applied to the hip. 

If a constitutional taint be suspected, our attention must be 
directed to it, and remedies given to combat it; thus we exa- 
mine carefully if the patient labours under scrofula, which is 
characterized by the softness of the flesh, discolouration of the 
skin, swelling of the upper lip and sides of the nostrils, and 
enlargement of the lymphatic glands in some, parts of the body, 
&c. &c. If it is discovered that scrofula has produced the dis- 
ease without the co-operation of any external cause, or if it has 
given the predisposition, and a fall has been the occasional 
cause, tonics must be administered, such as good wine, bitter 
vegetable infusions, extract of bark, &c. an issue is at tfre same 
time to be established at some distant part, to prevent the de- 
termination of the humours to the diseased joint. 

A large blister, applied to the hip, and renewed every twen- 
ty-four hours, produces very good effects. It seems to deter- 
mine to the skin the irritation that has taken place in the cavity 
of the joint, and the abundant serous discharge that it occa- 
sions, reduces the swelling of the affected parts j this discharge 
should be kept up by dressing the blistered surface with an 
irritating ointment. I have seen the best effects from a blister 
applied at the commencement of the disease; the limb, though 
somewhat elongated, was restored to its natural length by 
means of it. 

When all the means we have recommended, with perfect 
rest, the use of blisters, or any other stimulant, such as moxa, 
have been used in vain, and the constitutional taint has not 
been subdued, then all our endeavours should tend to arrest 
the progress of the disease, by favouring the astachment of the 
head of the femur to the bones of the pelvis. For this purpose, 
perfect rest of the limb is absolutely necessary. The leg and 
thigh should be kept extended; without this precaution, the 
patient, from his natural tendency to bend the limb, in order 
to diminish pain, may give it such a direction that it will be 
entirely useless to him after his recovery. Le Cat cites an in- 
stance cf this kind: the patient having escaped the dangers of 
a tedius suppuration, recovered, but the femur was grown to 



OF SPONTANEOUS LUXATIONS OF THE FEMUR. 277 

the os innominatum, so as to form a right angle with it: thus, 
from having neglected the precaution of keeping the thigh ex- 
tended, the limb was rendered not only useless but inconve- 
nient, and the person enjoyed but very imperfectly the advan- 
tages of his recovery. 

If, notwithstanding this treatment, abscesses form in differ- 
ent points of the tumour, they should be allowed to burst of 
themselves, in order that the admission of air into them may 
be retarded as much as possible-, and if it be deemed neces- 
sary to open them, the incision should be very small, and 
the operation deferred as long as possible. 

When fistulous openings are established, they should be 
dressed so as to prevent as much as possible the admission of 
air: and detergent injections, composed of barley-water, wine, 
and honey, a solution of alcali, or any other liquid more or 
less suited to the sensibility of the parts, should be thrown into 
the fistulous passages. The strength is to be supported, and 
every means used to resist the exhaustion occasioned by a long 
and copious suppuration. Mineral waters, extract, of bark, or 
syrup of bark for very young children, and a nourishing and 
invigorating diet, are to be used with this view. If the sup- 
puration diminishes, and a tendency to anchylosis is suspected, 
the thigh is to be extended as much as the pains will allow, 
and kept in that position by means of splints; these are neces- 
sary on account of the patient's constantly endeavouring to bend 
his thigh, in order to diminish pain. If the patient is young, 
the epoch of puberty is often favourable to him; the great re- 
volution which the solids and fluids undergo at this period, 
proves serviceable; the diseased parts exfoliate, the fistula? dry 
up, and the head of the femur attaches itself to some point of 
the os innominatum. We must not endeavour, by moving the 
limb, to establish a new articulation; for, by disturbing the 
head of the femur, the irritation might be renewed, the in- 
flammation increased, and the anchylosis, a very happy termi- 
nation of a disease in which the life of the patient is in so great 
danger, prevented. 

Secondary luxation of the femur downwards and inwards on 
the foramen ovale, is less frequent than that upwards and out- 
wards; however, many cases of it have been observed. A 
young man felt acute pains in his hip, which swelled conside- 
rably in a very short time; the limb became elongated, and 
was turned outwards; the knee and point of the foot were in- 
clined in the same direction; the leg was half bent, and a tu~ 



278 OF LUXATIONS OF THE PATELLA. 

mour appeared at the superior and internal part of the thigh 
in the perinseum: a fluctuation being discovered in the tumour, 
it was opened, a great quantity of pus escaped, and the patient 
found himself relieved. The operator was applauded for his 
success, but the pus, at first benign, soon became fetid: the 
patient was exhausted in a short time, and died. On opening 
the articulation, Citizen Boyer found the acetabulum destroyed 
by caries, which had committed some ravages also in the head 
of the femur. 

This luxation presents the same symptoms as the primary 
one in the same direction, and requires the same treatment as 
the secondary luxation upwards and outwards. When the 
patients recover by an anchylosis of the head of the femur with 
the bones of the pelvis, the lameness arising from the excess of 
length in the limb, is much more inconvenient than that re- 
sulting from its shortness. 



CHAPTER XIV. 



OF LUXATIONS OF THE PATELLA. 

THIS bone, placed on the anterior part of the knee, may 
be luxated upwards, downwards, outwards, and inwards, 
but the two last only, properly speaking, merit the name of 
luxation. The patella in fact cannot be luxated downwards, 
and descend below the knee, but when the tendon of the ex- 
tensor muscles of the leg is broken transversely: in which case, 
the tibia, in the flexion of the leg, will bring down the patella, 
and displace it in the same manner as it does the inferior frac- 
tured portion in a transverse fracture of this bone. 

Luxation upwards may depend on a rupture of the inferior 
ligament of the patella. This substance, though very thick 
and strong, and the tendon of the rectus anterior and triceps 



OF LUXATIONS OF THE PATELLA. 279 

muscles, of which it is only a continuation, are sometime bro- 
ken transversely, in which case, the muscles carry the bone 
above the condyles of the femur, as they draw up the superior 
piece in transverse fractures of it. It is easily seen, that the 
dislocations of the patella, in these two cases, is only the effect 
of the rupture of the tendon of the extensors of the leg, or of 
the ligament which unites it to the tibia. 

Luxations inwards or outwards take place when the patella 
is violently pushed in one or other of these directions. Great 
relaxation of the inferior ligament of the patella may give a 
predisposition to them. Such was the case of the young man, 
the particulars of which are given by Citizen Itard, in the 
Medical Journal ; the relaxation of the inferior ligaments was 
such, that the patellae were luxated outwards by the slightest 
motion of the knees. 

Of the lateral luxations, that outwards is the most frequent. 
This may arise from the internal edge of the patella projecting 
more than the external, which disposition is favourable to the 
action of the means by which it is pushed outwards, and from 
the extent of the articulating surface of the external condyles 
of the femur, which allows the patella to slide easily on it. 

The external condyle of the femur naturally more eminent 
anteriorly than the internal one, may be depressed; and this 
depression, whatever may be the cause of it, favours luxation 
in this direction. I have seen among the military conscripts, 
three cases of luxation of the left patella outwards, which ap- 
peared to depend on this cause. In these three individuals, 
from twenty to twenty-two years of age, the patella was placed 
at the external side of the condyle, without having, however, 
entirely deserted it; its anterior face was turned outwards, its 
posterior inwards; and its internal edge was placed anteriorly, 
and projected under the skin, and the external edge was di- 
rected backwards. The luxation had taken place in all during 
infancy. Nothing was easier than to replace the patella; it 
was done by relaxing the extensors of the leg and bending the 
thigh; but, unless confined to its place, it was soon again dis- 
located; pulled by the tendon of the extensors, and its inferior 
ligament, which had contracted an oblique direction, it slided 
along to the outer side of the knee. 

A patient, at this moment in the hospital Saint Louis, la- 
bours under a luxation of the patella outwards, occasioned by 
a gun-shot wound in the neighbourhood of the knee; the bone 
is easily reduced, but quickly abandons its situation. In all 






23o OF LUXATIONS OF THE PATELLA, 

such cases, the strength of the articulation of the knee is con- 
siderably diminished, and the whole extremity is reduced iri 
size. 

The patella is easily replaced, but difficultly kept in its situ- 
ation. The latter purpose might be accomplished, by applying 
a bandage about the joint, the pieces of which, embracing the 
sides of the patella, would fix it on the anterior part of the 
knee. But how is the derangement of this bandage to be 
guarded against in the motions of the knee, and what is to 
prevent the patella from passing outwards? None of the per- 
sons just mentioned found it necessary to apply for surgical aid; 
they suffered no great inconvenience from the luxation, and, 
as it exempted them from military service, they were little 
anxious to have it remedied. Indeed, it is very probable that 
no treatment would have been successful in such cases. 

Luxations outwards, produced by external violence, may be 
either complete or incomplete *, it is seldom complete, as it re- 
quires a very considerable violence to force the patella entirely 
from the external condyle of the femur. A gentle flexion of 
the knee favours it very much; in this posture, the muscles, the 
tendon of which is attached to the patella, are relaxed, and 
the .internal edge of the patella projects, and is favourably 
situated for the action of an external force impelled against it. 

Valentin, in his Criticisms on Surgery, gives a case of lux- 
ation of this kind. The Duke de Coigni, in galloping in the 
streets, struck his knee against the wheel of a carriage, and 
luxated the patella outwards. He was carried to the house of 
Botentuit, an ignorant, but very celebrated bone-setter, who 
made many endeavours to reduce the luxation, but which were 
fruitless on account of the position in which he had placed the 
limb; he kept the patient on his feet, and made him extend 
his leg forcibly. Valentin, family surgeon to the Duke, ar- 
rived, and reduced the bone with the greatest facility, by 
placing the patient on a bed, extending his leg, and bending 
the thigh towards the pelvis. 

A young man, in running in a room, knocked his knee against 
the corner of a trunk; the blow was so violent as to luxate the 
patella outwards. Citizen Sabatier was consulted; he endea- 
voured to reduce it, but met very great resistance. Citizen 
Boyer was called in: by using much force he effected the re- 
duction, but not without a great many attempts. 

In luxations of the patella outwards, the patient feels very 
acute pain, and cannot bend his leg; the knee is deformed* 



OF LUXATIONS OF THE PATELLA. 2% 1 



the pulley of the condyles of the femur is felt through the skin, 
and the patella forms a tumour before the external condyle; 
instead of the faces of the patella being anteriorly and poste- 
riorly, the anterior is become the external and the posterior 
the internal; the internal edge is turned more forwards than 
inwards, and the external is become nearly the posterior. This 
position of the patella has made some believe that it might be 
luxated by turning half over, that is, by placing itself per- 
pendicularly before the pulley of the femur, with one of its 
edges, now become posterior, lodged in the groove of the pul- 
ley. Others have even admitted the possibility of a complete 
inversion, in which the posterior face of the patella becomes 
the anterior. But it cannot be conceived, that the extensors 
of the leg, and the inferior ligament of the patella, could allow 
such an inversion to take place; and if the patella was only 
half inverted, and one of its edges rested on the pulley of the 
femur, the points of contact would be so hw, that it would 
slip into its natural position. 

The symptoms of luxation inwards are nearly the same as 
those just described: there is this difference, however, that the 
tumour formed by the patella is placed internally. In both 
species, if called in before the swelling takes place, we can feel 
through the skin the two faces of the patella; the posterior, 
excavated, turned towards the femur, and the anterior pro- 
jecting under the skin. 

A complete luxation cannot take place without great relaxa- 
tion of the inferior ligament, and tendon of the extensor mus- 
cles, or without very considerable external violence; in which 
case the luxation, easy to reduce, would not be the most dan- 
gerous symptom. 

In every species of luxation of the patella, reduction is to be 
effected as soon as possible. It is done by placing the patient 
on a bed with the leg extended and the thigh be#t In this 
position the extensor muscles and their tendon, as well as the 
inferior ligament of the patella are relaxed; and this bone may 
be moved and pushed with ease in the direction which the spe- 
cies of luxation requires. We think it is always possible to re- 
duce the patella, without making an incision in the integu- 
ments, and introducing a spatula under the bone. This ope- 
ration, though recommended, has never been performed, and 
never could, without bringing the patient into great danger. 

The noise made by the bone in reassuming its place, and the 
disappearance of the symptoms, announce the reduction; the 
36 



2$2 OF LUXATIONS OF THE 

patient can now bend and extend the leg. The inflammatory 
swelling, which generally supervenes, is to be subdued by bleed- 
ings and topical applications. This treatment, with a few days 
rest, will be sufficient; after some time the knee is to be moved 
gently, to prevent a stiffness of the joint, which, without this 
precaution, is very likely to take place. 



CHAPTER XV. 



OF LUXATIONS OF THE BONES OF THE LEG. 

THE tibia, at its articulation with the condyles of the 
femur, may be luxated in four different directions; viz. 
anteriorly, posteriorly, and laterally to either side of the knee. 
The luxation backwards is always incomplete; it could not be 
otherwise without a very great laceration of the soft parts. It 
is as often secondary as primary, and in such cases it is a con- 
comitant of white swelling, a disease much more grievous than 
the dislocation, and almost always requiring amputation. 

Luxation forwards is still more rare than that backwards; 
the ligaments of the knee and the greater part of the tendons 
surrounding it, being placed nearer its posterior than anterior 
part, prevent the too great extension of the leg. Luxations 
inwards and outwards are the most frequent. They are always 
incomplete, on account of the extent of the articulating sur- 
faces, and the strength of the part surrounding the articula- 
tion. They take place from the femur being drawn either in- 
wards or outwards, while the leg is fixed. 

The luxation backwards is distinguished by attending to the 
following circumstances: it is impossible to extend the leg; the 
patella, closely applied to the pulley of the femur, forms an 
eminence, under which there is an empty space, and the in- 
ferior ligament is extended obliquely downwards and back- 



BONES OF THE LEG. 25^ 

wards; and a projection formed by the extremity of the tibia, 
is felt in the ham, &c. &c. 

Symptoms of an opposite kind accompany the luxation for- 
wards. Those inwards and outwards are easily known from 
the deformity of the joint. In the first, the external condyle 
of the femur is lodged in the internal cavity of the tibia, and 
the internal condyle projects and forms a tumour at the in- 
ternal side of the knee: the contrary takes place in the se- 
cond. When they are complete, which is extremely rare, 
the tibia is carried entirely to the internal or external side of 
the femur. In every case of luxation the laceration of the 
ligamentous parts is so great, that the ends of the tibia and 
femur may be easily placed in their natural situations; there is 
scarcely occasion for even gentle extension and counter-exten- 
sion. It happens sometimes, notwithstanding the extent of the 
articulating surfaces, that a return of the luxation takes place 
from the great laceration of the parts which should confine the 
bones. To prevent this, an apparatus similar to that used in 
fractures of the thigh is to be applied. Disagreeable symptoms, 
occasioned by the laceration of the soft parts, are always to be 
expected; our attention should be particularly directed to mo- 
derate and subdue them. The antiphlogistic regimen must be 
strictly observed, and the other means of preventing and sub- 
duing inflammation had recourse to. If the inflammation ter- 
minates in suppuration, the abscesses are to be opened by 
making a large incision. In general, large openings are to be 
made in abscesses seated in the neighbourhood of joints, to allow 
a free evacuation of the pus, which by stagnating might become 
acrid, and attack the cartilages of the joint; but, if the abscesses 
be formed in consequence of a caries of the ends'of the bones, a 
very small opening is to be made, in order to prevent as much 
as possible the admission of air. If the inflammation terminates 
in gangrene, we must wait until nature has arrested the progress 
of the mortification, and then amputate. The separation of 
the living from the dead part, is marked by an inflamed circle. 
The progress of the mortification is very often so rapid that it is 
impossible to save the patient; and perhaps a complete luxation 
of the tibia from the femur may be considered as a case re- 
quiring immediate amputation. However, before a general 
precept of this kind can be established, it must be founded on 
observations well made and judiciously compared. 

The fibula is difficultly displaced from the tibia, with which 
it forms two articulations ; nevertheless we may conceive, that. 



284 OF LUXATIONS OF THE FOOT. ' 

in a violent and sudden turn outwards of the foot, if its liga- 
ments are naturally relaxed, it may slide from below upwards, 
so as to touch the external condyle of the femur. Citizen 
Boyer has seen a luxation of this kind in consequence of a dis- 
location of the foot outwards. By putting the foot in its na- 
tural direction, the fibula descended into its proper place. 
Compresses soaked in resolvent liquids were placed over the 
parts, and a roller was passed round the foot and leg, to pre- 
vent a return of the luxations. The patient had a tardy reco- 
very, and some stiffness of the foot remained, though the pre- 
caution of moving it, when the state of the parts would admit 
it, was not neglected. 



CHAPTER XVI 



OF LUXATIONS OF THE FOOT. 

THESE luxations are but seldom met with; the great vio- 
lence necessary to produce them, and the difficulty of 
effecting them, account for their unfrequency. Before they 
can take place, the astragalus must be partially or totally forced 
from the quadrangular cavity formed for it by the two bones 
of the leg, and in which it is received like a tenon in a mor- 
tice. The sides of the articulation are strengthened by very 
strong ligaments, which go from the tibia and fibula to the os 
calcis and astragalus, and by the two malleoli. An external 
violence, it is true, may distend or even break these ligaments; 
but its force being almost entirely spent in producing this effect, 
will not be sufficient to force the astragalus from the cavity in 
which it is enclosed. 

The foot may be luxated inwards or outwards, forwards or 
backwards, and the luxation in any of these directions may be 
complete or incomplete. Luxations inwards and outwards are 



OF LUXATIONS OF THE FOOT. 2^5 

the most frequent; the former however occurs more frequently 
than the latter: the internal malleolus not descending so low as 
the external, the astragalus has a less space to describe from 
without inwards, than in the contrary direction. It is occa- 
sioned by a violent abduction of the foot, and is easily known 
from the derangement of this part, the sole of which is turned 
outwards, and the back inwards; from the pain, and inability 
of moving the foot; and lastly, from the eminence formed be- 
low the internal malleolus by the astragalus. 

In the luxation outwards, it is equally impossible to move 
the foot; the sole is turned inwards and the back outwards, 
and the astragalus forms an eminence below the external mal- 
leolus. 

Luxations of the foot are always dangerous; their conse- 
quences may be so dreadful as to occasion death, and in very 
many cases they render amputation necessary. However, the 
prognosis is not always so unfavourable; for it is clearly pro- 
ved, that many patients have recovered without any thing ex- 
traordinary having occurred during their treatment. This in- 
validates the general rule laid down by J. L, Petit, to ampu- 
tate before twenty-four hours after the luxation. It is also now 
well ascertained that dislocations likely to produce the most 
mischievous consequences, have had a happy termination, and 
that this was the case, though the soft parts have been very 
much injured, the ligaments nearly quite ruptured, and the 
astragalus completely removed from the foot. 

The reduction should be accomplished as soom as possible, in 
every luxation of the foot; if deferred, the inflammatory symp- 
toms and swelling which supervene, will render it difficult and 
painful. To effect this, one assistant makes counter-extension 
by fixing the leg, and another draws the foot, whilst the sur- 
geon pushes the latter part in a direction contrary to that in 
which it was luxated. If the luxation be inwards, the external 
edge of the foot must be depressed by elevating the internal, 
when it is found that the ligaments yield to the extension : the 
contrary is done in luxations outwards. The articulation is 
covered with compresses moistened with resolvent liquids; and 
splints which reach below the sole of the foot, are applied on 
the inside and outside of the leg. 

Consequences more or less disagreeable are always to be ex- 
pected, which may be moderated or even prevented by copious 
and repeated bleedings. Sometimes, notwithstanding the enor- 
mous derangement and laceration of the soft parts, no bad 



286 OF LUXATIONS OF THE FOOT. 

symptom succeeds, and the patient recovers with an unexpect- 
ed rapidity; but in very many cases, violent inflammation su- 
pervenes and quickly terminates in gangrene. In other cases 
the inflammation terminates in suppuration, abscesses form and 
heal up, and the patient recovers. Sometimes, however, there 
is a caries of the ends of the bones conjoined with them. 

The experienced practitioner is to judge, from the nature 
and violence of the symptoms, when immediate amputation is 
necessary. A great number of observations posterior to those 
of J. L. Petit, prove that, by following his instructions, we 
should often amputate a limb which might be preserved. It is 
also ascertained by experience, that the astragalus may be ex- 
tirpated with advantage, when the laceration is such, that it is 
only attached by a few shreds of ligament. The tibia, in con- 
sequence of this extirpation, descends, and rests on the supe- 
rior face of the os calcis, to which it grows, and the patient 
recovers, it is true, with an anchylosed joint; but such a termi- 
nation is preferable to losing the foot by amputation, or run- 
ning the risk of the dangerous symptoms arising from preser- 
ving the astragalus. Ferrand performed this operation on an 
invalided soldier, who was in the habit of carrying the bone in 
his pocket, Desauit performed it three times with success. 
One of his three patients (a female) died three months after 
the operation; but she evidently fell a victim to an hospital 
fever, which was by no means connected with the complaint 
for which she was admitted into the hospital. On dissecting 
the foot, the extremity of the tibia was found already partially 
attached to the os calcis. There is no doubt but that the ope- 
ration would have been crowned with success, had the person 
survived the other disease. 

Fracture of the fibula near its inferior extremity, is a fre- 
quent complication of luxation of the foot inwards. This bone 
is to be carefully examined in all such cases, and the foot is to 
be supported, whether the fibula be fractured or not, by means 
of the ordinary apparatus for fractures of the leg. 

Luxations forwards and backwards, less frequent than those 
described, are however sometimes met with. The first is occa- 
sioned by a fall backwards, while the foot is fixed to the 
ground; the second by a fall on the feet, with the body inclined 
forwards, and the leg much bent. The luxation forwards is 
more difficultly produced than that backwards, on account of 
the articular pulley of the astragalus, which inclines towards 
the posterior side, being permitted to slide much on the tibia, 



OF LUXATIONS OF THE FOOT. 2%J 

without abandoning it in the extension of the foot. When 
the extension is carried too far, luxation forwards is produced. 

In the luxation backwards, the external and posterior liga- 
ments, and the posterior part of the capsule, are torn; in that 
forwards, the anterior and external ligaments, the anterior 
fibres of the internal lateral ligament, and the anterior part of 
the capsule, are torn. The symptoms of the first species are, 
a diminution of length in that part of the foot between the lower 
part of the leg and the anterior extremity of the toes, elonga- 
tion of the heel, tension of the tendo Achillis, and relaxation 
of the extensors of the toes. It is impossible either to bend or 
extend the foot: this symptom distinguishes luxation from 
sprain, in which the foot may be moved, though not without 
pain, however high the inflammation may be. 

Contrary symptoms accompany the luxation forwards : the 
foot is lengthened, the heel is shortened, and the foot, much 
extended, cannot be bent, &c. 

The reduction of both is easily effected -, after which it will 
be necessary to use effectual means to prevent a relapse. The 
mode of treatment to be afterwards observed, for subduing the 
unfavourable symptoms that supervene, is the same as that 
pointed out for luxations inwards and outwards. When gan- 
grene takes place in any luxation of the foot, we must defer 
amputation until its ravages are arrested. In cases where the 
inflammation is moderate, and the destruction of the soft parts 
not considerable, the articulation may be preserved; and to 
prevent a stiffness of the joint, the foot is to be moved as soon 
as circumstances will admit of it. 

The very thick and short ligamentous substance which unites 
the astragalus to the os calcis, binds them so strongly together, 
that they follow one another in their motions, and form, as is 
were, but one bone. Hence they are never completely sepa- 
rated, even in the most desperate cases of luxation of the foot ; 
but one or both of them may be luxated from the scaphoides 
and cuboides. The transverse direction of the articulation 
formed by these four bones, suggested to Chopart the inge- 
nious idea of amputating only a part of the foot. But these 
luxations, less dangerous than the others, can be occasioned 
only by a violent effort, in which the anterior part of the foot 
is fixed, as happened in the two cases related by J, L. Petit: 
the foot was fastened in an iron grate, whilst the body was 
drawn backwards. The astragalus and os calcis may, under 
these circumstances, be luxated, but particularly the former, 



288 OF DROPSY OF THE ARTICULATIONS. 

the head of which slides from below upwards, in the cavity of 
the posterior face of the scaphoides, and forms a tumour on 
the back of the foot. The inflammatory swelling renders it 
often difficult to ascertain this luxation. It is not easily re- 
duced, even shortly after it has taken place. Citizen Boyer 
failed in a case of this kind, in which the head of the astraga- 
lus was luxated upwards and inwards, by a fall from a horse ; 
but in some time the person felt no inconvenience from the 
affection, he could walk without pain or lameness, and nothing 
remained but the deformity occasioned by the tumour. 

The other bones of the tarsus and metatarsus are too strongly 
tied together to admit of luxation. The phalanges of the toes 
cannot be luxated by external violence, on account of their 
shortness. However, the possibility of luxation of the first 
phalanx of the great toe from the first bone of the metatarsus 
may be easily conceived. It is not necessary to give here the 
rules to be followed in such a case. They consist in reducing 
the luxation, and amputating the great toe, when the state of 
the soft parts renders it impossible to preserve it. 



CHAPTER XVII, 



OF DROPSY OF THE ARTICULATIONS. 

THE synovial fluid, which lubricates the surfaces of all 
the joints, may be accumulated in such quantity in the 
capsule which secretes it, as to form a disease called by authors 
hydarthrus, or dropsy of the joint. Though the possibility of 
this accumulation taking place in all the articulations may be 
conceived, yet there is no well-attested instance of this happen- 
ing in any of them but in the knee. 

Dropsy of the joints seldom depends on a general affection 
of the svstem, and rarely co-exists with other dropsical af- 



OF DROPSY OF THE ARTICULATIONS. « 289 

Sections, such as hydrothorax, ascites, and anasarca. It ap- 
pears to be a partial affection, and to be produced by local 
causes, which act by destroying the balance between the ex- 
halation and absorption of the synovia. The accumulation of 
this sero-albuminous fluid seems to arise in most cases from an 
increased exhalation, and not from a diminution of absorption. 
In fact, affections of this kind come on, in general, from vio- 
lent exercise of the articulation, from fatiguing the ligaments, 
and from the repeated friction of it's surfaces ill too long and 
laborious exercise. 

Motion, as we have established in another Work, is the prin- 
cipal stimulus by which the secretion of the synovia is increased, 
and the fluids determined to the joint. This determination is 
considerable in proportion to the friction and pressure of the 
ends of the joint against one another. When this stimulus is 
Carried to a certain degree, an active exhalation, or rather 
slight phlogosis, is produced, and the serous secretion is very 
considerably increased. It is in a similar way that dropsies of 
the breast and abdomen are often occasioned by a slow and la- 
tent inflammation of the pleura or peritoneum. 

The nature of the remote causes of hydarthrus corroborates 
what we have advanced concerning its formation. It is very 
often a consequence of acute rheumatism, and sometimes forms 
a crisis of that disease. Many observers, and particularly 
Storck, have remarked the tendency which acute rheumatism 
has to terminate by an effusion of a sero-lymphatic fluid into 
the cellular substance in the neighbourhood of the joints of the 
lower extremities, or into the interior of the joint itself. The 
more rapid the progress of the inflammatory symptoms, the 
more prompt is the effusion, consequently it takes place slowly 
in chronic rheumatism and in chronic gout. The swelling of 
the joints in these complaint's, and the deposition of matter 
which takes place into the parts about the articulation, may 
also produce an increased exhalation of synovia. The pains 
which accompany white swellings often occasion an accumula- 
tion of synovia in the capsule of the joint. I have seen, iri 
dissecting two of these swellings of the knee, the synovia col- 
lected nearly to the quantity of two ounces. 

But we must remember that the inflammation which pro- 
duces dropsy of the joint is only slight; if very considerable, it 
would suspend the secretion of synovia, and give rise to anchy- 
losis by "the mutual adhesion of the dried surfaces of the joint. 
We are decidedly of opinion,, that tlie articulation bfthe knca 
37 



2gO OF DROPSY OF THE ARTICULATIONS. 

•only has hitherto presented a collection of synovia sufficient to 
merit the name of dropsy: such an accumulation never takes 
place in the hip joint, though J. L. Petit attempts to explain 
spontaneous luxations of the femur from this cause. 

We must not confound this disease with encysted tumours, 
which are sometimes formed on the sides of the knee near the 
patella. The latter are circumscribed, and a fluctuation is felt 
in them; they are not accompanied with pain or discolouration 
of the skin; on opening them, an albuminous fluid escapes, 
and the sides of the cyst are made to adhere to one another by 
pressure ; or when this does not succeed, by means of an irri- 
tating injection, which excites an inflammation on its surface. 
This practice is free from danger, because the cyst is shut on 
all sides, and has no communication with the interior of the 
joint. "We must also take care net to confound with dropsy 
of the joint certain white swellings, in which the cellular sub- 
stance, distended with fluid, presents a kind of fluctuation. 
This symptom is particularly apt to lead into error in swellings 
of the cluster of lymphatic and sebaceous glands situated above 
the patella, betw r een the tendon of the extensor muscles of the 
leg and the anterior and inferior part of the femur. In the 
commencement of some white swellings, this tissue, distended 
with lymph, elevates and pushes forwards the tendon of the 
extensors of the leg, displaces the patella, and raises it up; 
from the condyles of the femur. In these cases, the patella is- 
replaced by pressure, and the swelled mass being displaced, 
forms two tumours at the sides of the tendon, which are tense 
and elastic, and have an internal motion; but the sensation^ 
communicated by this motion is very different from that occa- 
sioned by the undulation of a fluid: it is like that of something: 
slipping from under the finger. However, there is such simi- 
larity in these symptoms, that an inattentive surgeon may be 
easily led into error. 

Arthritic, (Edematous, and white swellings of the knee, and 
foreign bodies formed in it, are accompanied with symptoms 
so different from those of dropsy of this joint, that there is no 
occasion to point them out here. The marks by which the 
existence of the latter affection is ascertained are these: a dull 
pain is felt in the articulation, the knee loses its oval form, and 
presents an irregular colourless tumour, in which a fluctuation 
is felt at those places where the capsule is slack, and forms little 
round eminences which project about the joint. The most con- 
siderable of these are placed at the sides of the patella, which- 



OF DROPSY OF THE ARTICULATIONS. 2£I 

is itself pushed upwards by the fluid, but it may be replaced by 
bending the leg. The form of the tumour is varied by the mo- 
tions of the knee; but it always projects more at the anterior 
part of the articulation than in the ham, at which place the 
synovial membrane presents only a small surface, and is sup- 
ported by the cross ligaments which pass behind it. A fluctu- 
ation is felt by striking the tumour; the thinness of the soft 
parts renders it very easy to ascertain the undulation of the 
fluid. The nature of the disease is sufficiently manifest when 
all these symptoms are present. 

The prognosis is unfavourable, on account of the difficulty 
•of discussing the tumour, and the danger of a caries of the car- 
tilages and ends of the bones, or an anchylosis, supervening. 

As dropsy of :t-he knee-joint never depends on the causes 
which produce general dropsy; and as, instead of appearing in 
persons labouring under general debility, it is always met with 
in the strong and robust, a particular mode of treatment is re- 
quired in it. Stimulants, purgatives, diuretics, or sudorifics, 
are either useless, or at least can give but a very feeble assist- 
ance. It is from topical applications that benefit is to be ex- 
pected. The mildest of these are to be commenced with, and 
they in general succeed in recent cases, in which the effusion 
has not been considerable, and has been suddenly formed in a 
crisis of acute rheumatism, or any other acute disease. Resol- 
vent liquids, such as camphorated spirit of wine, frictions with 
a brush, or warm flannel impregnated with some aromatic va- 
pour, with volatile camphorated liniment, alcohol, ether, or 
even with mercurial ointment as advised by Bell, determine the 
fluids to the skin, increase the insensible perspiration of which it 
is the organ, and promote the absorption of the effused fluid. 
Fumigations with the vapour of vinegar, from which Monro 
witnessed good effects, with the vapour of benzoin and other 
balsams, and pumping with warm water in which neutral salts 
have been dissolved, act in the same manner. "But of all iopiccj. 
stimulants, the most active and most effectual is a blistering 
plaster, in which the proportion of cantharides is not so consi- 
derable as to cause great vesications. Tralles used synapisms, 
and Storck applied cataplasms of the ranunculus. We must, 
however, take care not to carry the use of these remedies so 
far as to disorganize the structure of the cellular tissue, which 
often occasions ulcers difficult to cure, and extremely painful. 
For the same reasons we are not to use cupping and scarifying 
but with great circumspection. 



2^2 OF DROPSY OF THE ARTICUL ATIONS. 

When all these means have been used for a sufficient time 
without any benefit, and when the tumour impedes the mo- 
tion, and causes a contraction and atrophia of the limb, we 
must have recourse to a surgical operation. It consists in ma- 
king a puncture with a trocar into the cavity of the tumour, 
and allowing the water to escape through the canula. This 
operation, though easily performed, is a delicate and danger- 
ous one, on account of the admission of air into the joint. 
The contact of air has not, as we shall see in treating of wounds 
of the articulations, all the bad effects attributed to it by au- 
thors. However, the morbid state of the synovial membrane, 
and the irritation already existing in it,' may render it more 
sensible to the impression of this fluid than it would be were 
there no disease in the joint ; and, in fact, cases have occurred 
in which the qualities of the synovia were considerably changed 
by the contact of air: this fluid, instead of being inodorous, ac- 
quired a disagreeable odour, lost its transparency by the mix- 
ture of a purulent matter, produced an inflammation which 
extended to the capsule and cartilages, and at last occasioned a 
caries of the ends of the bones. 

To prevent these direful consequences, and the introduction 
of air which occasions them, a superficial incision is to be made 
in the skin at the most projecting part of the tumour; after 
which, the lips of the wound are to be much separated, and 
the trocar used in the operation for the hydrocele, pushed cau- 
tiously in an oblique direction from the bottom of the incision 
into the cavity of the tumour. The skin collapses after the 
evacuation of the water, and covers the puncture made by the 
trocar, the canula of which is to be drawn away when all the 
water has drained off. 

When the operation is finished, the patient is to be put to 
bed with his knee half bent ; the joint is to be covered with 
cloths wet with spirituous liquors, or other astringent fluids, 
with the view of preventing the return of the effusion. We 
will mention, in the chapters on white swellings and anchylo- 
sis, the treatment to be adopted in cases in which the synovia 
has its qualities changed, and produces caries or anchylosis, 



*93 



CHAPTER XVIII. 



OF FOREIGN BODIES FORMED IN THE 
ARTICULATIONS. 

THE foreign bodies which are formed and developed in the 
interior of the articulations, are to be carefully distin- 
guished from arthritic concretions deposited in their neighbour- 
hood. These foreign bodies, which alone will be considered 
in this chapter, may take their origin in the inside of every ar- 
ticulation in which there is motion. They have been found in 
the articulation of the lower jaw with the temporal bones, in 
that of the wrist with the bones of the fore-arm, and that of 
the foot with the leg ; but no joint is more subject to them than 
the knee. Ambrose Pare has made mention of these substan- 
ces; latterly, practitioners have directed their attention to them, 
and have proposed methods of removing them. 

These foreign bodies have various appearances, and are found 
m greater or less quantity : sometimes they resemble a frag- 
ment of cartilage, which moves about in the joint, but which 
is attached to the capsular membrane; at other times they are 
detached, hard, and, as it were, inorganic, and can be moved 
to any part of the joint. A concretion of this kind, the size 
of a large hazel-nut, was found in the knee of a woman who 
died in the hospital Saint Louis. Citizen Fourcroy, who has it 
m his possession, compares it to tubercles found in certain fishes, 
for instance, to those on which the prickles of the ray-fish are 
elevated. As to their number, it varies, from one, which is 
the most common, to twenty-five, a number at first sight very 
considerable, but for which we have the incontestable evidence 
of the illustrious Morgagni. Their size is very variable ; some 
have been found of an inch and a half in their greatest diameter, 
whilst others have scarcely equalled the size of a lentil. They 
have generally the form of this seed, but they have been met 
with of various forms, as long, oval, rough, or broken on 
fheir surface, concave, or convex. The chemical analysis of 
them shews that the cartilaginous ones are chiefly composed of 



294 OF FOREIGN BODIES 

albumen, and the hard solid ones principally of phosphate of 
lime. 

It is difficult, without doubt, to give an explanation of the ori- 
gin and growth of these substances, but it is certain that they al- 
ways impede mere or less the motion of the joint in which they 
grow. Sometimes they succeed to the swelling and contusion 
occasioned by a fall or blow on the knee •, at other times they 
are formed spontaneously without any apparent cause ; and in 
both cases their presence is indicated by tumefaction of the 
knee, which is increased by rest, and diminished by moderate 
exercise. Are they formed by the crystallization of the salts 
held in solution by the synovia, in the same way as the crystal- 
lizable parts of the urine form calculi in the bladder ? How, in 
this case, do they become organized ? for many of them have 
vessels, and evident marks of organization. Theden supposed 
that they were formed by a portion of the synovial cluster 
of glands on the outside of the capsule, which was bruised 
and nearly detached by the shock occasioned by a false step. 
Some authors have imagined that they were portions of car- 
tilage detached from those covering the ends of the bones, 
or placed between them. Morgagni ascertained that they 
could not originate in this manner, for the articulation and car- 
tilages were perfectly sound and whole in the subjects in whom 
they were found in the greatest number. Nothing then is 
more obscure than the etiology of this affection. Happily, 
though its causes are involved in obscurity, it is easily distin- 
guished, and can be treated with great hopes of success. 

If these substances are free and detached, they can pass ea- 
sily from one part to another of the articulation, and enter in- 
to all its corners ; in this case, it is difficult to establish the ex- 
istence of them, but it is particularly difficult to extract them j 
the moveable body, whilst we are making the incision to ex- 
tract it, may slide from the place where it projected under the 
skin, and fall into the cavity in the posterior part of the knee. 
Sometimes it occasions no pain : this arises from the body be- 
ing fixed in some place in which it does not impede the motion 
of the knee ; as, for example, at the sides of the patella, or 
of the tendon of the extensors of the leg. At other times it 
occasions much distress: this is caused by its being placed be- 
tween the posterior face of the patella and the articular pulley 
of the femur. As it can occupy alternately these different 
places, it is easy to explain, as Bell observes, why patients af- 
fected with this complaint are often roused from their sleep by 



FORMED IN THE ARTICULATIONS* 295: 

sharp pains arising from the change of situation of the body 
during sleep. 

A more or less considerable enlargement takes place round 
the knee during the continuance of the pains, but it is still easy 
to feel the body through the skin and capsule. It forms an emi- 
nence under the integuments, and may be pushed in any di- 
rection, and made to project at the internal or external sides of 
the inferior ligament of the patella, at the internal or external 
sides of this bone itself, or of the tendon of the extensors of 
the leg. Sometimes the laxity of the integuments and capsule 
is so great, that we can seize the body and twist it. Desault 
has seen a case of this kind. 

It is impossible to obtain a resolution of these substances. 
This desirable termination cannot take place but by means of 
vital action ; now, this action is so little to be expected in the 
greatest number of them, they being in some degree inorganic, 
and topical stimulants and resolvents can act wit!} so little effect 
through the integuments, that the removal of them by these 
means is scarcely to be looked for. Some English surgeons 
have proposed to fix and confine the body in a part-of the ar- 
ticulation where it could not impede motion, and where.it 
might form an adhesion with the capsule 5 but how are we to 
confine a body which tends incessantly to change its situation ? 
Besides, the adhesion cannot be formed without a certain de- 
gree of inflammation in both surfaces, of which the foreign 
substance is very rarely susceptible. Lastly, should the adhe- 
sion, which requires a certain degree of organization in the body* 
take place, the concretion would be susceptible of growth, 
and in time would impede, by its size, the motion of the knee. 

The most simple, prompt, and certain method of cure, is 
the extraction of the foreign body, an operation always easily 
performed, and free from danger, if the following rules are 
observed. The patient being stretched on his back, with the 
leg extended, in order to relax the soft parts at the anterior of 
the articulation, the surgeon looks for the foreign body, and 
bringing u to the internal side of the patella, at which place 
the capsule is very lax, fixes it with his thumb and fore-finder. 
An assistant draws outwards the skin over the patella, and the 
surgeon makes a longitudinal incision, through the integuments, 
on the body. The incision should be made deep enough by 
one stroke of the knife, and proportioned to the size of the 
body to be extracted. Sometimes it is forced through the in- 
cision by compressing it between the fingers. If it be attached 



296 OF FOREIGN BODIES 

by a fold of the capsule, which serves it as a ligament, this 
is to be divided with a history or scissars; if there be occa- 
sion to enlarge the incision, it is to be done with the knife ; 
and pincers, or other instruments which may lacerate, bruise, 
or occasion inflammation of the surfaces of the joint, are never 
to be introduced. The substance beinjr extracted, the assistant 
removes his hand, and leaves the skin to its own elasticity, 
which brings over the wound in the capsule the portion of the 
integuments which had been drawn to one side. 

By making the incision in this way, the admission of air into 
the joint is prevented, and all the bad consequences, such as 
inflammation, suppuration, and caries, are obviated. 

After having extracted one, or as many bodies as may be 
found in the articulation, the lips of the wound are imme- 
diately brought together by means of adhesive plaster ; some 
compresses, wet with resolvent liquids, are applied over the 
joint, and the whole dressing is supported by some turns of a 
roller drawn pretty tight. The leg is to be placed on a pillow, 
and kept extended, in order to relax the soft parts about the 
incision, and thus prevent pain and the approach of inflamma- 
tion. 

Though the precaution of making the incision in the skin, 
in a line different from that in which it is made in the capsule, 
is rational, yet it is not absolutely necessary to the success of 
the operation. Many surgeons have omitted it, and afterwards 
obtained the immediate union of the divided parts; which 
proves, as will be mentioned in treating of wounds of the 
joints, that wounds of the articulations are attended with less 
danger than the ancients and a great number of the moderns 
have imagined. The pain occasioned by the extraction is in- 
considerable, but it may be acute, if the patient be extremely 
sensible to impressions, or if a considerable branch of the in- 
ternal saphena nerve, which is very variable in its direction, 
come under the edge of the history. The loss of blood, when 
even one of the articular arteries is divided, is very inconside- 
rable; it scarcely merits the name of haemorrhage, and is easily 
stopped by bringing together the sides of the wound. For 
some days after the operation, the compresses should be fre- 
quently moistened with resolvent liquids, and the knee kept 
perfectly at rest; the patient should not be permitted to rise 
before the fifteenth or twentieth day, though the wound may 
have cicatrized in the first week; for it is much better, in these 
cases to carrv precaution too far, than to be deficient in it. 



FORMED IN THE ARTICULATIONS. 297 

When, on account of the admission of air into the articula- 
tion, or the improper use of instruments in extracting the body, 
inflammation takes place, it is combated by emollient applica- 
tions and copious and repeated bleedings. If abscesses form, 
they are to be opened; and when the symptoms have abated, 
the limb is to be gently moved, and the motion increased every 
day, in order to prevent a stiffness of the joint. All the ob- 
servations that we have made here respecting these bodies are 
applicable to those only found in the knee; and this is the only 
joint on which it has been necessary to perform an operation in 
order to remove them. Their presence in other articulations 
would not be so easily discovered, neither would it cause the 
same inconveniences. Should extraction, in these cases, be 
necessary, the operation would be so much the more danger- 
ous, as the joint is deep-seated, and surrounded with import- 
ant parts. 



CHAPTER XIX. 



OF WOUNDS OF THE ARTICULATIONS. 

ALL the ancient writers on surgery speak in the same 
terms of the danger of wounds of the articulations*, and 
almost all modern authors are of their opinion. We will prove, 
in this chapter, that wounds of the articulations, sometimes 
followed by serious consequences, often heal with the greatest 
facility, and that the apprehensions of authors respecting them, 
are unfounded. 

A man was wounded in the elbow by a piece of glass, which 
penetrated into the cavity of the joint. The glass was extract- 
ed, and the lips of the wound were brought together, and 
supported by adhesive plaster; his recovery was quick, and 
not interrupted by any unfavourable circumstance. 
38 



29$ OF WOUNDS OF THE ARTICULATIONS. 

Another man was wounded by a small sword in the same 
joint*, he was carried to the hospital de la Ckarite. On examin- 
ing the wound, it was found that the capsule of the joint was 
opened. This wound healed like the most simple puncture. 

As the practitioners of all ages have agreed in referring the 
danger of wounds of the joints to the admission of air, the fa- 
cility with which punctured wounds of the articulations heal, 
may be accounted for from the narrowness of the wound, and 
the difficulty opposed to the insinuation of air. But experience 
also proves, that wounds of the joints, by cutting instruments, 
are not very dangerous, though the admission of air into them 
is manifest. 

A Massacreur of the second of September, who seized by the 
hair a prisoner of the Abb aye Saint Germain, received en his wrist 
the blow levelled at the head of the victim. The posterior part 
of the articulation was entirely opened, and the convexity for- 
med by the scaphoides, semilunaris, and pyramidalis, aban- 
doned the ends of the bones of the fore-arm. He was admit- 
ted into the hospital de la Charite ; the lips of the wound were 
immediately brought together *, the hand was kept much ex- 
tended by means of a splint ; the skin, tendons of the extensor 
muscles, and the capsules, all healed by the first intention, and, 
at the end of twelve days, he was discharged, quite cured. 

A boy employed in the kitchen of the hospital de la Charite, 
had the articulation of his wrist opened by a piece of a vessel 
of delph ware *, the lips of the wound were brought together, 
and the patient recovered in a very few days. 

A shoemaker's wife opened with a sharp cutting instrument 
the articulation of her wrist on the external side, for about one 
third of its circumference ; the tendons of the radiales externi, 
extensores, and long abductor of the thumb, were divided. 
Citizen Boyer was called in •, he closed the wound, which 
healed by the first intention, and was cicatrized on the third 
day. 

The facility with which the incisions made in the joints for 
the purpose of extracting foreign bodies, heal, proves also, that 
wounds of the articulations are not attended with so much dan- 
ger as has been generally supposed. But though the facts 
just related, fully invalidate the opinions of the ancients, yet it 
must be allowed that such a happy termination does not always 
take place. Cases sometimes occur, in which the wound is 
followed by a violent inflammation that terminates in gangrene, 
or lays the foundation of a caries of the ends of the bones. 



A. 



OF WOUNDS OF THE ARTICULATIONS. 259 

These melancholy consequences, as the ancients have well ob- 
served, seem to be brought about by the contact of air, which 
excites an inflammation of the synovial membrane. But that 
this cause can produce these effects, it must be continued for 
some time, and must make a considerable impression on the 
capsule and cartilages. The imprudent application of charpie, 
or any other dressing, to the surfaces of the joint, produces still 
more dangerous consequences. A man received a sabre-wound 
on the external side of the wrist, which opened the articula- 
tion; he was brought to the hospital de la Charite ; one of the 
monks, who then directed that institution, filled the wound 
with charpie ; an enormous swelling took place, gangrene su- 
pervened, and the patient died. 

The danger is equally great when the wound suppurates ; the 
purulent matter, formed in the joint, irritates the parts, and 
causes an exfoliation of the cartilages, or caries of the ends of 
the bones. These consequences are also to be apprehend when 
the wounding instrument has not only penetrated into the joint, 
but wounded the cartilages, or ends of the bones. A young 
man received a sabre-wound in the anterior and external part 
of the knee, which entirely divided the patella ; the lips of the 
wound were brought exactly together ; but a great swelling came 
on, and excluded every hope of union by the first intention. The 
dressings were taken off, the parts were covered with a cata- 
plasm, and the patient was bled ; but the swelling continued to 
increase, an abscess formed above the patella, between the 
femur and the triceps cruralis, and the entire limb became 
much swelled. Death soon ensued, and, on dissection, the 
patella was found divided, and the cartilages partly disorgan- 
ized. 

Another young man received in a duel a sabre-wound on 
the anterior part of the point of the shoulder, which opened 
the articulation of the humerus with the scapula, and divided 
the end of the clavicle next the scapula, the deltoid muscle, 
and a portion of the great pectoral muscle. The wound was 
immediately dressed by bringing its sides together, but a hae- 
morrhage came on the third day, which made it necessary to 
remove the dressing. The vessel was too deep-seated to be 
discovered and taken up ; an attempt was made to stop the hae- 
morrhage by stuffing the wound, after which a violent inflam- 
mation supervened, which terminated in the formation of 
enormous abscesses. The patient died, and the articulation 
was found full of pus. 



300 OF WOWNDS OF THE ARTICULATIONS. 

A young man, aged eighteen years, received a sabre-wound 
in the inferior part of the left arm •, the weapon came obliquely 
from above downwards, and cut off entirely the external con- 
dyle of the os humeri. The wound was not dressed for two 
days after the accident, at which time he was brought to the 
hospital de la Charite ; the divided parts were now brought to- 
gether, but the swelling soon obliged us to relax the' f strips of ad- 
hesive plaster; emollients were applied; pus and synovia flowed 
abundantly from the wound, especially when pressure was made 
on the sides of the articulation; abscesses formed; the fever 
assumed a bad aspect; the swelling extended to the whole of 
the limb, and the patient was on the point of dying; amputa- 
tion of the arm was now had recourse to, by which the pa- 
tient's life was saved. On opening the articulation, the soft 
parts surrounding it were distended with pus, the joint itself 
was filled with a fetid purulent matter, the cartilages were 
nearly destroyed, and the head of the radius was somewhat 
carious. 

What inferences are we to deduce from all these facts ap- 
parently contradictory? What prognosis are we to form in 
wounds of the articulations ? What treatment is adapted to 
them? The prognosis must be necessarily doubtful; it is fa- 
vourable, when the wounded joint is superficial, the wound in 
the integument and capsule riot extensive,' and consisting of a 
simple incision without contusion ; when no vessel is opened, 
or principal nerve wounded ; and, lastly, when with these fa- 
vourable circumstances the admission of air has been prevented 
by quickly closing the wound. 

The principal indications of cure are, to bring the divided 
parts into contact, to exclude the air, remove foreign sub- 
stances, and keep the limb free from everything that might ex- 
cite inflammation. When this practice is not successful, we must 
combat the inflammation, open the abscesses, prevent the stag- 
nation of the pus by making counter-openings ; and, lastly, 
amputate the limb, when preserving it brings the patient's life 
in danger, * • 



3° I 



CHAPTER XX. 



OF WHITE SWELLINGS OF THE JOINTS. 

THE name of lymphatic tumour, or white swelling, has 
been given to swellings of the joints, unaccompanied 
with symptoms of inflammation. Such is the definition of 
them given by Bell in a Dissertation on White Swellings, at 
the end of his Treatise on Ulcers. In fact, an increased heat 
and discoloration of the skin are never observed, at least in the 
beginning of these swellings ; there is simply a tumefaction of 
the part, with pain more or less deep seated. The English 
author just mentioned has very justly marked out two principal 
varieties of this disease. 

In the first, called rheumatic, the patient feels dull pains in 
the whole of the limb, before the appearance of the tumour, 
which is often a critical termination of rheumatism. The pain 
now becomes fixed in the joint, and diminishes in violence ; 
the soft parts surrounding the articulation swell more or less \ 
but there is no change in the colour of the skin, nor is there 
an increase of heat. If the disease be seated in the knee, the 
patient keeps the leg more or less bent, in order to relieve pain ; 
the muscles, tendons, and even soft parts, from remaining in 
this contracted state, become stiff, and hence results contrac- 
tion or rigidity of the limb, or even a complete anchylosis. 
The pains increase by degrees, the swelling augments and dis- 
tends the skin ; inflammation takes place, which terminates in 
suppuration, and the formation of abcesses in the cellular sub- 
stance ; these burst spontaneously, and leave fistulous openings. 
Through these fistulas flows a whitish or serous matter, at first 
inodorous, but it is soon vitiated by the cornier, of air, and be- 
comes fetid. The disease extends its ravages from the soft 
parts to the cartilages and ends of the bones. The leg is con- 
siderably diminished in size ; this may depend on the impedi- 
ment to the distribution of the fluids, by the pressure made on 
the vessels by the enlarged and indurated parts, or rather on 



^02 OF WHITE SWELLINGS OF THE JOINTS. 

the swelled joint drawing to itself most part of the fluids, and 
thus diminishing the quantity which should go to nourish the 
leg. The immobility of the limb tends also to diminish the 
nutrition of the leg, since it is found that the emaciation ex- 
tends to the inferior part of the thigh. The skin, excessively 
distended, becomes inflamed and ulcerated ; the veins become 
varicose, and burst ; and the patient, exhausted by the conti- 
nuation of pain, and the absorption of purulent matter, drags 
on a miserable existence for some time, and dies. 

The course of the disease is described here as it takes place 
in the knee, which is its most usual seat ; but the articulations 
of the elbow, hip, wrist, and foot, are by no means exempt 
from it. 

On dissecting the diseased joint, the soft parts are found in- 
durated, decomposed, and in a confused, greyish mass, some- 
what resembling lard. The swelled ligaments form one body 
with the cellular substance ; the cartilages preserve, in some 
cases, their natural colour ; in others, especially when the af- 
fection has continued long, they and the ends of the bones are 
affected with caries. The cellular tissue placed behind the infe- 
rior ligament of the patella, between the femur and the tendon 
of the extensors o£ the leg, in the ham, and behind the cross 
ligaments of the knee in the interval between the condyles of 
the femur, has also the colour, appearance, and consist- 
ence of lard. In some cases, collections of a bad purulent 
matter are found in different parts of the cellular substance. 

The white swelling produced by a scrofulous taint, which 
establishes itself in the great articulations, has sometimes an 
appearance, and pursues a course similar to that just described ; 
at other times dull, deep-seated, and circumscribed pains pre- 
cede it, and announce its formation. The swelling is at first 
scarcely perceptible, and when it becomes more considerable, 
it is perceived, that it arises almost entirely from an augmenta- 
tion of volume in the ends of the bones, and that the integu- 
ments scarcely participate in the morbid state. The limb be- 
comes emaciated and contracted, the pain appears confined to 
the centre of the joint, and to the extremities of the bones ; 
emollient and anodyne applications neither appease the pain, 
nor produce a resolution of the swelling -, lastly, the patient, 
exhausted by his sufferings, perishes. On opening the knee, 
every part is found in a natural state, except the cartilages, and 
ends of the bones, which are affected with caries. 



OF WHITE SWELLINGS OF THE JOINTS. 2°3 

It Would be too tedious to describe the different forms under 
which this disease may present itself; after pointing out its two 
principal varieties, it will be sufficient to remark, that it dif- 
fers so much in different individuals, that it is scarcely accom- 
panied by the same symptoms in two patients. 

"White swellings are sometimes produced by rheumatic affec- 
tions j but most generally they originate from a scrofulous taint. 
They seldom appear to be produced by an external cause, 
hough they s ometimes follow strains that have been neglected, 
or badly treated, and fractures in the neighbourhood of the 
joints. Sometimes the swelling comes on rapidly without any 
apparent cause. Such was the case of a young man, whose 
arm I have lately amputated for a white swelling, and caries of 
the elbow joint. Lastly, a blow, fall, or any external violence, 
may produce the swelling in a scrofulous person, in whom the 
cause of the disease seems to be easily called forth. 

The enlargement of the ends of the phalanges, considered 
by some authors as a species of spina ventosa, belongs to the 
class of white swellings. This disease, as has been already ob- 
served, affects both the substance of the bones and their arti- 
culations. 

The prognosis is always unfavourable, whatever may be the 
age or constitution of the patient, the cause or duration of the 
disease. The tumours are very seldom discussed *, they almost 
uniformly resist the numerus remedies with which they are 
combated. In some fortunate cases, the disease, arrived at a 
certain pitch, makes no further progress ; the pains diminish, 
and in time disappear ; the limb remains contracted ; the ends 
of the bones grow to one another, and the patient escapes 
death, but has an anchylozed joint. 

In the greater number of cases, the patient, harassed by vi- 
olent pains, is exhausted by the copious suppuration, hectic fe- 
ver, and colliquative diarrhoea, and no resource is left but the 
amputation of the affected parts. The prognosis is somewhat 
less unfavourable in cases of children who have not yet attained 
the age of puberty. This period, so favourable for the cure 
of scrofula, brings about also that of white swellings, by de- 
stroying the evil which is its most frequent cause. 

The diseases the most difficult to cure, are those in which 
the greatest number of remedies have been used ; we must not 
then be astonished at the multiplicity of means proposed for the 
cure of white swellings. These, whether adopted on rational 



304 OF WHITE DWELLINGS OF THE JOINTS. 

principles, or recommended empirically, must be adapted to 
the variety of the disease, and the stage in which it exists. 

The limb must be kept perfectly at rest : without this pre- 
caution, the remedies cannot produce any good effect ; for the 
motion of the affected parts augments the primary cause of the 
disease. Thus, in white swellings of the knee, the patient 
should remain in bed, with his leg as much extended as the 
pains, and tendency which he has to bend it, will permit. If 
he be young and vigorous, and if an external cause has produ- 
ced the disease, or contributed to its developement, or if it 
has been occasioned by a rheumatic affection, some blood may 
be taken away in the beginning of the disease. The aliments 
should be mild, and taken in small quantities at a time; the 
drinks should be refrigerant and copious ; and the diseased 
joint should be covered with an emollient cataplasm, which is 
to be renewed twice a day. Such are the means for subduing 
the inflammation which is in some degree latent in the joint ; to 
these may be joined the application of leeches, or even scarifi- 
cations, which Bell prefers, and by which he says we may draw 
away at once eight or ten ounces of blood. When the pains 
diminish, and the tumour tends to a resolution, the emollients 
are rendered somewhat repellent ; a cataplasm made of the 
root of briony boiled in milk may then be applied with advan- 
tage. Black soap, brought to the consistence of a liniment 
by means of camphorated spirit of wine, has been also em- 
ployed with some benefit. Frictions about the knee, with a 
volatile liniment, composed of an ounce of oil and half an ounce 
of ammonia, have been found useful. The joint is to be rubbed 
twice a day with this liniment, and afterwards covered with a 
piece of fine linen that has been soaked in the same substance. 

Mild laxatives, such as tamarinds, cream of tartar, dissolved 
in whey, or different laxative salts dissolved in veal broth, 
are to be administered at the same time. They cause a 
determination of the fluids to the intestines, and thus divert 
them from the diseased articulation. Lastly, when the ir- 
ritation and inflammation are abated, the most active resol- 
vents are to be used. Blisters are then applied to the articula- 
tion, and sometimes the blistered surface is made to suppurate, 
and the discharge is kept up by a stimulating ointment. Bell 
recommends, strongly, frictions, with mercurial ointment, which 
have, he says, the double advantage of introducing into the 
system a powerful solvent, and increasing the action of the skin. 
They are to be frequently repeated every day, and continued 
until the mcuth is gently affected. 



OF WHITE SWELLINGS OF THE JOINTS. 2° 5 

Le Dran, and many other practitioners, have advised to 
pump warm water on the affected joint. To derive from this 
practice its full effect, the water must fail from an elevated place, 
be used as warm as the patient can bare it, and be rendered 
stimulant by a neutral salt, or an alcali, dissolved in it. It is in 
this way that pumping is used in the hospital Saint Louis, 
which contains a greater number of patients labouring under 
white swellings than any other hospital in Paris. The mineral 
waters of Bareges and Bourbonne, &c. may be used in a similar 
manner. Warm baths, of a diluted alealine solution, and va- 
pour baths of the same solution, have been recommended. 
Much benefit is said to be derived from a kind oY animal bath 
used in the following manner, the patient introduces the af- 
fected joint into an opening made in the belly of an animal re- 
cently killed, and keeps it for some time among the warm in- 
testines. The mild temperature and unctuosity of this bath, 
produces an effect similar to that obtained by folding the omen- 
tum of a sheep round the joint, as recommended by Bell. 

Very violent means, such as the actual cautery, and burn- 
ing with moxa, often produce a diminution of the swelling ; 
but some enlargement still remains, and the pain becomes in- 
tense. By such powerful stimulants, the state of the patient 
is rendered more distressing, his disease is aggravated, and its 
progress is accelerated. 

When the treatment is successful, the joint remains for a 
length of time incapable of motion, and very often anchylo- 
zed. But the incapability of motion must not be always consi- 
dered as a certain mark of anchylosis ; it often depends only on 
the stiffness of the soft parts, and particularly of the tendons. 
This may be remedied in time, by moving the litnb every day, 
and gradually increasing the motion ; and by the use of warm 
baths, pumpings, and fomentations. However, all interference 
whatever should be abstained from, when there is a suspicion 
that the ends of the bones are unsound, or anchylozed ; endea- 
vours to move the limb, in such cases, would cause so much ir- 
ritation as to reproduce the primary affection. 

In cases W-here the white swelling is evidently scrofulous, the 
antiphlogistic plan cannot be pursued ; tonics and corroborants 
are then to be administered, with which may be combined the 
application of solvent and stimulant plasters, such as the soap 
plaster, that of acuta* &c. &c. Often in these cases, as in 
the preceding, however assiduous and rational the treatment, 
the swelling continues to increase • at first, hard and elastic in 
39 



306 OF WHITE SWELLINGS OF THE JOINTS. 

some places, it soon points, and a flu£hiation is felt in it ; ab- 
scesses burst spontaneously, and their openings degenerate into 
fistulx. 

Some empirics have been daring enough to irritate the tu- 
mour with acrid and stimulating applications, in order to- con- 
vert the languid swelling into a phlegmon, and afterwards ob- 
tain a termination of it either by resolution or suppuration. 
Fabricius ab Aquapendente mentions a case of this kind, in 
which a charlatan enveloped the knee with a synapism of a very 
acrid vegetable. An active inflammation took place, which, 
combated in the ordinary way, terminated by resolution ; and 
the patient recovered the entire use of his knee. But this 
case cannot serve as a rule ; in the greater number of instances 
in which a similar treatment would be followed, it would infal- 
libly accelerate the progress of the swelling, and caries of the 
ends of the bones, increase the sufferings, and hasten the 
death of the patients. 

When there are many abscesses about the joint, and the col- 
lections of pus are considerable, it is necessary to prevent the 
stagnation of this fluid, and the absorption of it, by enlarging 
the fistulous openings, and renewing the dressings repeatedly. 
It is sometimes useful in these cases to pass a seton in the fistu- 
lous passage. This favours the escape of the purulent matter, 
and impedes the introduction of the air. If the pains be pe- 
netrating and excessive, their intensity may be diminished by 
the external and internal use of sedatives and opiates ; but 
when they are not appeased by these remedies, but become 
more intolerable, and take away the patient's rest ; and when 
hectic fever, a constant diarrhoea, and colliquative sweats, 
bring on marasmus, and endanger the patient's life, the am- 
putation of the limb, the last resource in such an invincible 
disease, must be had recourse to. We must not, however, 
be in too great a hurry to perform this operation, lest the pa- 
tiefct accuse us of precipitance in taking away a limb which 
might be preserved. Besides, a state of debility is extremely 
favourable for most surgical operations, and for amputations in 
particular. It obviates violent inflammation, the troublesome 
consequence of every operation in which a great number of sen- 
sible organs are concerned. However, we do not understand, 
by a state of debility, that state in which the patient is exhaust- 
ed and harassed by the continuance of the disease, diarrhoea, 
and colliquative sweats. Bell appears to recommend deferring 
the operation until this state of exhaustion has taken place. A 



OF WHITE SWELLINGS OF THE JOINTS. 2°1 

<iangerous precept. If observed, the patient, consumed by 
marasmus, will be no more able to furnish organic action suf- 
ficient for the healing of such a wound as results from amputa- 
tion. 

In order to determine on the necessity or impropriety of this 
operation, the state of the patient must be attentively examined, 
the resources of nature considered, and what is to be fear- 
ed, and what may be hoped for, maturely weighed. If the 
disease is recent ; if no suppuration has yet taken place ; 
if the pains are supportable \ and if the patient preserves his 
plumpness and vigour, the use of the means likely to produce 
a resolution of the swelling is to be persisted in. It would be 
-contrary to all rule to amputate in this case ; for, on the one 
hand, the violence of the inflammatory symptoms is to be 
dreaded ; and, on the other, the cause of the disease inherent 
in the solids, and diffused in the fluids, has not yet fixed itself 
entirely in the joint. We must therefore defer operating until 
it is firmly established in the articulation ; and until, consumed, 
as it were, by the production of the disease, it is rendered in- 
capable of changing its situation, or taking a new residence in 
another joint.* 

Lastly, the operation is not to be performed but in cases 
where one joint only is affected ; if many articulations, the 
knee and elbow for instance, are attacked, we must not think 
of operating. In reality, it is doubtful if death be not prefer- 
able to the mutilation that would result from such operations ; 
besides, the danger attending them would diminish very much 
the probability of their success. It is, then, only in affections 
of the small joints, such as the phalanges, that the different 
parts can be extirpated. When many of the principal articu- 
lations are affected at the same time, and the disease is advanced, 
death is inevitable. 

A practice less terrifying than amputation, inasmuch as it 
does not deprive the patient of his limb, has been proposed in 
cases of white swelling. It consists in cutting off, or extirpa- 
ting, the carious extremities of the bones, when the state of 
the soft parts admits it. 

• How will the physiologists of this country receive this reasoning ? It J$ 
evidently founded on the doclrine of the humoral pathologists. It may be 
asked, what evidence is there, that the cause (in the opinion of the author) 
so firmly fixed in the solidi, and widely diffused in the fluids, abandons 
its spacious residence to confine itself in a single joint ? and why the solid* 
And fluids do not manifest some appearance of its having deserted them ? 

Translator. 



JOi> OF WHITE bvVILLlNGS OF Tl-IL JOINTS. 

This operation is practicable only in cases where the affec- 
tion is confined to the ends of the bones, and extends but very 
little to the soft parts. If, for instance, the cellular tissue and 
ligaments about the knee are swelled, and collected into a ho- 
mogeneous lardy mass, no person would think of performing 
it. It is, then, confined to cases in which the bones only are 
affected. In an affection thus limited, which is by no means 
frequent* the ends of the bones are cut off in this wav. : 

If the head of the humerus be diseased, which is ascertained 
by an attentive examination of the tumour, and particularly by 
the introduction of a probe through the fistulas which commu- 
nicate with the articulation, the operation is commenced by ma- 
king on the external and upper part of the arm two longitudi- 
nal incisions, directed obliquely downwards, and distant, from 
one another about two inches at their superior part, but ap- 
proaching as they descend, and uniting in the form of a large 
V. . A triangular flap formed of the skin and deltoid muscle, 
is preserved in this way. It is dissected and raised upwards by 
detaching the muscle from the superior and external part of the 
humerus ; it is then committed to an assistant, and the surgeon 
bringing the elbow forwards and inwards with his left hand, 
cuts the orbicular ligament of the articulation with his right : 
the ligament is made tense by the direction given to the arm 
by this motion of the elbow. The tendons of tbe.subscapula- 
ris, infraspinatus, supraspinatus, and teres minor, are to be 
cut at the same time : this being done, the head of the hume- 
rus is easily luxated upwards and outwards, without cutting 
the tendons of the pectoralis major, latissimus dorsi, and teres 
major, which has been recommended, but which could not be 
done without danger, of wounding the brachial vessels and 
nerves. The head of the humerus being thus luxated, the ex- 
tent of the caries is ascertained ; next, the glenoid cavity of the 
scapula is examined, in order to discover if it be affected ; a 
plate of lead or piece of pasteboard is then placed under the 
head of the humerus to protect the soft parts, and the carious 
portion of the latter bone is sawed off. During the act of saw- 
ing, an assistant prevents the humerus from descending, and 
at the same time keeps it fixed and motionless. 

The circumflex artery is the only vessel to be taken up in Ibis 
operation j it is found at the posterior and superior part of the 
triangular flap. • 

The extirpation of t! A e head of the humerus was first prac- 
tised by White; the patient recovered in four months, and 



OF WHITE SWELLINGS OF THE JOINTS. 309 

his arm, shorter by nearly two inches, preserved its shape and 
strength. Bent, of Newcastle, as he relates in the sixty-fourth 
volume of the Philosophical Transactions, performed soon after- 
wards the same operation. Since this period, many English 
surgeons say they have performed it. Vigarous, of Montpellier, 
has also given a case of it in a Memoir presented, to the Acade- 
my of Surgery in 1774. 

Park, a surgeon of Liverpool, conceived and executed the 
bold projecl of extending to the articulations of the knee and 
elbow, the operation performed on the humerus by White. 
But in these cases, the. circumstances are much more unfavour- 
able, and the cutting off the ends of the bones much more 
difficult. Nevertheless, Park has performed the operation with 
success, on the knee of a man thirty-three years of age, and of 
a robust constitution. This surgeon made two parallel inci- 
sions along the sides of the patella, which extended to two 
inches above, and two below this bone; one of the articular 
arteries was divided and taken up; a transverse incision was 
made at two inches above the joint, and another at two inches 
below it ; one comprised the half of the thickness of the thigh, 
the other, half of that of the leg; all the anterior ligaments 
were cut, and the patella was removed, after which a knife was 
insinuated behind the femur, to separate the flesh from the 
bcnes, to the extent of about four inches. The edge of the 
knife was kept close to the posterior part of the bones, in order 
to avoid wounding the popliteal vessels and nerves. The inci- 
sion behind the bones being thus made, a plate of lead, or a 
large spatula, was introduced into it, in order to protefl the 
vessels and nerves of the ham from the saw. In this ease two 
inches. were cut from the femur, and one inch from the tibia; 
the bones were then replaced, their ends brought into contact, 
and the angles of the wound were closed by a few stitches. 
The disagreeable symptoms that succeeded were numerous and 
distressing, notwithstanding the relaxed state of the soft parts; 
however, in about four months the patient was able to walk. 
The ends of the bones grew together ; the knee was turned 
outwards; the limb, shortened by three inches, supported the 
weight of the body very well ; and the patient could walk with- 
out the assistance of crutches. 

There are few surgeons intrepid enough to undertake a si- 
milar operation. The lesion of the popliteal vessels and nerves, 
the violence of inflammation, and an abundant suppuration, 



JIO OF A.VCHyLOSIS. 

are the perils to which a patient is exposed, to preserve a limb 
always deformed, and not more useful than a wooden leg. 

When the elbow is to be operated on, the incisions must be 
made on the posterior side of the joint, as the principal vessel* 
and nerves are placed on the anterior side. As to the rest, the 
same rules are to be observed as in the preceding case. 



CHAPTER XXL 



OF ANCHYLOSIS. 



ALL affections of the articulations, which consist of a total 
or partial immobility of the joint, are comprised under 
the general denomination of anchylosis. It is said to be in- 
complete, when there is only a stiffness of the joint °, and com- 
plete, when all motion is impossible, from the ends of the 
bones growing together. It is further distinguished into dry 
and suppurating; but the last is a symptom of white swelling. 
Anchylosis is seldom a primary disease, it almost always suc- 
ceeds to another complaint. Thus it is seen to take place after 
fractures, particularly when in the neighbourhood of joints j 
after sprains, luxations complicated with contusion, or badly 
reduced, and white swellings, &c. &c. Diseases foreign to 
the bones, such as an aneurism of the popliteal artery, or 
abscesses formed in the neighbourhood of a joint, may occa- 
sion it. In a word, every thing that keeps a joint motionless, 
tends to produce an anchylosis, and one so much the more 
complete, as the limb remained long without motion. Anchy- 
losis from inaction appears to arise from the gradual diminution, 
or even total cessation, of the secretion of the synovia. It is 
well known that the friction of the ends of the joints excites 
the secretion of this fluid. 



OF ANCHYLOSIS, 3 I I 

One may conceive the possibility of a complete anchylosis 
taking place in all the joints of the body, from being confined 
to bed for a length of time, without motion.* The secretion of 
the synovia diminishes gradually, and at length ceases entirely ; 
then the surfaces of the joint, deprived of this fluid, and de- 
siccated, are attacked by an adhesive inflammation, similar to that 
which takes place in the pleura, and which in a vast number of 
cases occasions an adhesion of the costal portion of the pleura 
to that covering the lungs. The ligaments, tendons, and soft 
parts surrounding the articulation, acquire during the inaction, 
a rigidity which is difficultly removed ; this may arise from the 
vital power of the parts being rendered torpid by the inactivity; 
or from the growing together of the different parts of the cel- 
lular substance ; or from its becoming more dense from the in- 
spissation of the lymph and fat deposited in it. 

Having said so much on the formation of anchylosis, let us 
see what is the influence of the various causes which produce it. 
When a bone is fractured in the neighbourhood of a joint, the 
limb is kept motionless by the apparatus, during the whole pe- 
riod of ossification or union of the ends of the bone ; besides, 
the inflammatory swelling which constantly supervenes, extends 
to the articulation, and attacks the ligaments, capsule, and in 
general all the surrounding parts. Sometimes it only increases 
the consistence, thickness, and rigidity of these parts *, at other 
times it produces a mutual adhesion of the surfaces of the joint, 
by impeding the secretion of the synovia. This Is one of the 
principal reasons for reputing fractures of bones near their ex- 
tremities, more dangerous than those of their centre. How- 
ever, the latter are always followed by more or less stiffness in 
the articulations of the fractured bone ; but this arises from the 
state of inactivity, in which the limb has remained, and it may 
be removed by exercising the limb gently, and increasing the 
motion gradually. 

The stiffness succeeding to fractures has been for a long time 
attributed to an effusion of bony matter into the interior, or 
cellular substance in the vicinity of the joint. This matter, 
say the ancients and moderns, is a kind of glue which unites 
more or less completely the ends of the bones, and at the same 
time indurates the soft parts. This theory, which is found fn 
the treatises of J. L. Petit and Duverney, is abandoned, since 
the existence of an osseous juice is rejected, and the formation 

* No\iveaux Elemens de Phyaiologi?, tome ii. chap. Dcs Mouvemens. 



312 OF ANCHYLOSIS. 

of callus in fractures better understood. Besides, dissections 
of anchylozed joints have never discovered the osseous concre- 
tions, which should result from such supposed effusions. The 
dpinjon, that a change, or inspissation, of the synovia, was 
the most frequent cause of anchylosis, is not better founded. 
On dissecting a joint in which a complete anchylosis has taken 
place, the ends of the bones are found united at one point ; and 
in this part the surfaces have lost their natural polish ; but the 
parts which have not formed an adhesion, preserve their polish, 
and their surfaces are lubricated by a small quantity of synovia, 
not different from that found in the healthy state. 

However various the causes of anchylosis, the mode in which 
it takes place is always the same : when desiccated, inflamed, 
and sometimes even suppurating, as happens in some white 
swellings with caries of the ends of the bones, grow together ; 
when it is incomplete, that is to say, when it consists of a diffi- 
culty of motion in the part, and the impossibility of perform- 
ing the same motions as in the healthy state, the surfaces of 
the joint are still contiguous, and the disease exists only in the 
soft parts surrounding the articulation. 

It is essential to distinguish these two species, since the first 
or true anchylosis is altogether incurable, and is to be consi- 
dered, in most cases, a happy termination of a grievous disease. 
The false or incomplete anchylosis is rather a consequence of 
disease, than a primary affection. When a considerable abscess 
takes place in the vicinity of a joint, for instance near the wrist 
or joints of the fingers, the destruction of the cellular substance 
occasions a stiffness which it is impossible to prevent j but when 
the tendons exfoliate, the bones to which they are attached re- 
main motionless, and a complete anchylosis inevitably ensues. 
Therefore, when abscesses form near the joints of the fingers, 
and when they are followed by exfoliation of the tendons, the 
fingers should be bent, in order that they may anchyloze in 
that direction, which is much less inconvenient and much more 
favourable for the various uses of the hand, than permanent 
extension. On the contrary, when there is a suspicion that 
the knee will remain stiff", after the operation for a popliteal 
aneurism, the leg must be kept as much extended as the pains 
will permit. The same conduct is to be observed, when, after 
a spontaneous luxation of the femur, it is perceived that the 
head of this bone will attach itself to the pelvis, and that the 
disease will terminate by anchylosis. In these cases, as well 
as in every other, when the bones are grown together^ even 



©F ANCHYLOSIS. 313 

though the limb may have a bad and inconvenient direction, it 
would be imprudent, or even dangerous, to endeavour to de- 
stroy the adhesions, In fact, it could not be done without 
using considerable violence and causing great pain, and would 
be followed by inflammatory symptoms that would renew the 
adhesion, or by caries of the bones, which might occasion the 
death of the patient. 

When the false or incomplete anchylosis is apprehended, 
measures should be taken to prevent it. These consist in mo- 
ving the affected limb as much as the state of the soft parts will 
permit. This precaution is much more necessary in affections 
of the ginglymoidal articulations, than in those of the orbi- 
cular, on account of the tendency of the former, from the 
great extent of their surfaces, the multiplicity of their ligaments, 
and small extent of motion, to become anchylozed. The ex- 
ercise of the joint, by extending the contracted soft parts, calls 
forth their vital properties, and promotes the secretion of the 
synovia, by causing a friction of the articulating surfaces. A 
crepitation, arising from the synovia being deficient, is first 
heard ; but as soon as this fluid is secreted in greater quantity, 
and lubricates the surfaces of the joint, this cracking noise 
ceases. A certain share of precaution is to be used in moving 
the limb ; the motion, if rudely performed, might cause pain, 
and induce a swelling and even caries of the ends of the bones. 
It is by proportioning it to the state of the limb, and increasing 
daily its extent, as the soft parts yield and grow supple, that 
good effects can be derived from it. The exercise of the joint 
is not to be left to the patient himself, neither is it to be con- 
fided to ignorant persons, who might think that they moved 
the anchylozed joint, while the motion took place in the one 
above it. It is thus that a patient labouring under a stiffness of 
the elbow, if directed to put that joint frequently in motion, 
moves the entire upper part of the arm, by making the hume- 
rus turn in its articulation with the scapula. If inflammation 
be excited by these attempts, they must be suspended until the 
inflammation is subdued, and not recommenced until the pain 
ceases. We are often obliged to use considerable force in elon- 
gating contracted muscles, and it is to the great violence em- 
ployed in such cases that ignorant bone setters are often in- 
debted for their success. 

The efficacy of the exercise of the joint is increased, and its 
effects seconded, by warm baths, emollient applications, by 
frictions with the grease of fowls and other animals, and espe- 
40 



3I4 OF THE DIVIATIONS OF BONES, &C. 

dally by poui ilig warm water on the part, from a very elevated 
situation. Animal baths, and the other means mentioned in 
the chapter on white swellings, may be also used. When all 
these means fail, the warm waters of Bourbonne, Bareges, Spa, 
B^th, and Aix in Savoy, or other warm mineral waters, may 
be ha 3 ecc irse to. The inconvenience arising from the dis- 
these mineral waters is new happily removed, as those 
-daily, are found to be fully as effectual 
as those rom the mineral spring itself. Citizen Paul 

and C instil Jted an establishment for this purpose; 

'ready the waters of Bareges and Loueche, &e. are pre- 
pared artificially, and used at this place m the form of bdths or 
.xess. For this we have the testimony 
ecTxir of the establishment, 



CHAPTER XXII 



OF THE DEVIATIONS OF BONES, 

AND THE MEANS USED FOR PREVENTING AND CORRECTING 
THE DEFORMITY ARISING FROM THEM. 

THE bones, which give proportions to our different parts, 
and by which we are maintained in the erect posture, 
may grow in an unnatural direction ; and like the branches of a 
tree, whose growth is impeded by any cause, may bend under 
the weight of the body and the action of the muscles, so as to 
render motion extremely inconvenient. But it is only in in- 
fancy, when the tissue of the bones is flexible, and the ossifi- 
cation incomplete, that this vitiated conformation can take 
place. Affections of this kind are very easily prevented, but 
are very difficult to remove, and' are entirely incurable unless 
encountered before they have attained a certain degree. 



OF THE DEVIATIONS OF BONES, &C. 315 

They are sometimes occasioned by neglect in the clothing 
and exercise of children j in other cases, they arise from a want 
of equilibrium in the action of certain antagonist muscles. Thus 
confining children in swaddling-clothes, the use of stays, pre- 
mature exercise, and the habit of remaining in bad attitudes, 
as frequently occasion them as the difference arising primarily 
in the action and disposition of the muscles. 

Physicians had, for a long time, raised their voice against 
the barbarous use of swaddling-clothes, in which the limbs of 
the infant were so clogged, and kept in such a state of inac- 
tivity, that they could neither grow nor acquire strength ; hut 
it remained for the persuasive eloquence of Jean-Jacques to ef- 
fect a revolution in this part of physical education, which rea- 
soning could not produce.* 

Children are, now-a-days, scarcely ever wrapped up in swad- 
dling-clothes : they are generally covered with wide and warm 
vestments, which protect them from \he cold, and at the same 
time do not prevent the developement of their organs. 

The use of stays is no less objectionable. The breast and 
superior part of the abdomen is surrounded with these cuirasses? 
with the view of diminishing their capacity, and giving to the 
waist a delicacy altogether unnatural, and consequently remote 
from beauty. But they are not only injurious to beauty alone, 
their effects are pernicious to health % wide above, and growing 
narrow downwards, they resemble a cone placed inversely to 
that formed by the thorax, which is naturally wider at its in- 
ferior part than at its summit. The breast, subjected to con- 
tinual compression, must become deformed, and have its form 

* "All our wisdom consists in servile prejudices ^ all our customs are 

" subjugating, painful, and restrictive. Civilized man draws his first 
'* breath, and expires— in slavery j at birth, he is laid in swaddling-clothes, 
" when dead, he is nailed down in a coffin. A^ long as he preserves the 
** human figure, he is enchained by our institutions 

tc The new-born child has need of stretching himself and moving his 
*« limbs, to shake off that torpor, in which, rolled up like a ball, he has 
" remained for so long a time. His limbs are extended, it is true, but 
" confined in such a manner that he cannot move them ; his head is tied 
" down by stay bands j it would seem to be feared that he should have 
" the appearance of being alive. 

** Thus the impulsion from within, or the tendency of the internal 
" parts to grow and be developed, meets an insurmountable opposition. 
" The infant makes continual, but useless efforts, which exhaust his 
f* force, and retard the accession of strength. He was more at his ease, 
** less cramped, and less compressed in the amnios, than in his new si- 
•« tuation j I do not see what he has gained by coming into the world." 



3 l6 OF THE DEVIATIONS' OF fc0NES 3 CZC. 

changed from conical to oval, or both its extremities made nar- 
rower than natural ; hence, in consequence of the lateral de- 
pression of the ribs, the action of the lungs is impeded, diffi- 
culty of respiration brought on, and a remarkable disposition 
to phthisis pulmonalis induced. However, though the habitual 
wearing of stays may be attended with these disadvantages, 
still they are not to be altogether proscribed, as there are cer- 
tain cases in which they may be used with some advantage. 

Let us suppose, for instance, the shoulders of a child to be 
of a different height, which inequality may be the result of a 
bad habit, or may be occasioned by the muscles on each side 
not possessing the same degree of force. If the right shoulder 
be lower than the left, the child should wear stays in which the 
notches under the arms are not on a level ; that in the right 
side should not be so deep as that in the left, in order to raise 
up the right shoulder. By the continued use of this apparatus, 
the muscles of the left side recover strength enough to balance 
those of the right, the habit of remaining in a bad attitude is 
interrupted, and the child is restored to his natural shape. It 
would be in vain to recommend the child to incline to the op- 
posite side, as a force which he could not subdue, causes, un- 
known to him, the deformity. It is necessary, that the pressure 
made by the corset against the arm-pit keep him constantly in 
mind of making resistance to the depression of the shoulder, by 
throwing into action the muscles of the opposite side. 

The vertebral column, naturally curved by the weight of 
the body, is liable to many deviations. We have treated of 
those arising from rickets : we will mention here those only 
that arise from another cause. Children, from their sight be- 
ing naturally very weak, or from contracting a habit of stooping 
their head to inspect substances closely, bend the neck beyond 
its natural limits •, jf this habit be neglected, and nothing done 
to correct it, the bones become indurated in this curved situ- 
ation, and the head remains always inclined forwards. The 
same thing happens in the back or loins of young persons of a 
delicate constitution. The extensor muscles of the trunk, too 
weak to support the spine, allow it to be preternaturally bent 
by the weight of the head, thoracic and abdominal viscera. 
The nature of the person's occupation influences very much 
the direction in which the curvature takes place. The breast 
and shoulders are consequently deformed -, the former becomes 
prominent on the side towards which the curvature tends, and 
is depressed on the opposite side. The use of stays stuffed at 



OF THE DEVIATIONS OF BONES, &C. 2 l 1 

the side, opposed to the curvature or prominence of the spine, 
is then to be recommended ; or the machine of Levacher, de- 
scribed in the fourth volume of the Memoirs of the Academy 
of Surgery, may be used. A vertical piece of iron ascending 
along the spine, and embracing the back part of the head by 
two wings reaching to the forehead, and a circular bandage to 
keep the head extended, are the principal parts of this inge- 
nious machine, repeatedly applied with success by the inventor 
of it. If the head only is bent forwards, a pasteboard stock 
very high anteriorly may be worn. Whatever mechanical 
means are used, they should be applied in such a manner as 
not to impede in the smallest degree the motion of the affected 
parts. In fact, it is an essential point to combine exercise with 
them, which it is known is the best means of re-establishing 
the strength of the enfeebled muscles. Tonics, cold bathing, 
friction, a nourishing diet, and, in short, every thing recom- 
mended in the treatment of rickets, are to be combined with 
the use of machines. 

If the child be very young, and cannot walk without the 
assistance of leading-strings, the precaution must be taken of 
sewing these to a broad girdle, so attached to the child's clothes 
that it may support the entire body without ascending up under 
the arm-pits, and thus compressing the axillary nerves and 
vessels. In general, the use of girdles and leading-strings is 
injurious; children should be left to themselves, and not forced 
to walk before their strength admits of it. Premature walk- 
ing, by making the legs bend under the weight of the body, 
render them sometimes bowed ; at other times the loiees are 
turned inwards, that is to say, the child is in-kneed, and the 
feet are turned outwards ; for^the position of the feet is always 
influenced by that of the knees ; thus, when the knees are 
turned inwards, the feet are turned outwards, and vice versa. 

It is important to know this relation necessarily resulting 
from the disposition of these parts, when we attempt remedy- 
ing their mal-conformation. It is on the knowledge of it that 
is founded the simple but efficacious practice of raising the in- 
ternal edge of the foot, when the knee inclines too much in- 
wards ; and of raising, on the contrary, the external edge, 
when the knee is turned outwards, and the leg bowed. 

When a child, from having been put to walk too soon, or 
from any other cause, shall be in-kneed or bow-legged, nothing 
is to be done in the first case but to have the internal edge of 
the sole of the shoe made somewhat thicker j and in the se- 



3 1 8 OF THE DEVIATIONS OF BONES, &C. 

cond, to have the same done to the external side. The con- 
stant adduction and abduction of the foot, if this simple pre- 
caution be attended to, influences in time the knee, and insen- 
sibly makes it straight. This treatment will be certainly suc- 
cessful if the child be young : his bones, flexible at this time, 
will yield easily to the force used to straighten them. 

There is another species of mal conformation, in which the 
feet are turned entirely either inwards or outwards. Persons 
labouring under this distortion, to whatever side the sole of the 
foot is turned, are said to be club-footed. The Romans dis- 
tinguished two species of this deformity : they call those van 
whose feet were turned inwards, and valgi those whose feet were 
turned outwards. 

In the first species, the sole of the foot is turned inwards, 
its internal edge becomes the superior, and its external the in- 
ferior : the toes are bent j and the back of the foot, turned 
outwards, is usually more arched than natural. The contrary 
circumstances are observed in the second species. In both, 
the deviation of the foot, when carried to a certain degree, 
renders progression extremely difficult. 

This deformity is occasioned by an inequality in the respec- 
tive force of the adductors and abductors of the foot ; which 
inequality may depend on the position in which the foetus was 
placed in the womb, or on the manner in which it has been 
treated after birth. 

Nothing is easier than to discover the affection, even though 
very inconsiderable ; the leg itself is deformed and curved out- 
wards if the sole of the foot is turned inwards, and vice versa. 
It is of the greatest importance to oppose the deviation of the 
foot at the moment that it begins to take place. The bones are 
then soft, cartilaginous, and flexible, and take any form given 
to them ; but as the person advances in age, they become hard, 
preserve the false position in which they have been drawn, and 
the part remains forever deformed. 

. As the foot is oftener turned inwards than outwards, the 
most useful apparatus in the greatest number of these cases, 
consists of a boot or buskin, to the sole of which is attached a 
spring bent into a semicircle. This boot is to be worn by the 
patient in such a manner as that the convexity of the same cir- 
cle may bear against the external part of the leg. The spring 
thus curved, attached below to the sole of the foot, and above 
to the external and superior part of the leg by means of a broad 
knee-band, tends constantly to become straight, presses oh the 



OF THE DEVIATIONS OF BONES, &C. 2 J 9 

external side of the leg, and at the same time serves to bring,, 
the foot outwards. If its use be persisted in from a very early 
period until the process of ossification is finished, the limb may 
be brought to its natural direction. But it is impossible to ef- 
fect this when the treatment has not been commenced early, 
and before the parts have acquired their entire consistence. In 
such cases, the patients should wear the boot and spring during 
his life. 

The internal use of tonics should be combined with the ap- 
plication of this apparatus, for frequently these distortions are 
accompanied with symptoms which indicate a state of cachexy 
or general debility. 

When, in consequence of a burn, a limb remains contracted, 
the cicatrices must be destroyed, and the limb brought to its 
proper direction, and kept so by means of a proper apparatus 
until the wound is healed. If, after an extensive burn of the 
palm of the hand, the fingers are contracted and kept con- 
stantly bent, an incision must be made into the cicatrix, but 
not deeper than the skin, lest the vessels^ nerves, and tendons, 
so numerous in this part, might be wounded, and the fingers, 
after being extended, must be attached to a broad piece of 
board placed on the back of the hand. By this means the 
wound will heal, while the fingers are kept parallel to the bonea 
of the metacarpus. 

A little girl was admitted into the hospital de la Charite, 
with her fingers reverted on the back of her hand in conse- 
quence of a burn : the fraena, which confined them, were di- 
vided transversely behind the articulation of the first phalanges, 
with the bones of the metacarpus : the fingers were brought to 
their natural direction, and fixed so by means of a board pla- 
ced on the palm of the hand, and some lint was put between 
the lips of the wound. Each finger was tied by a little band 
which passed through the clefts of the board, so that the wounds 
on the back of the hand might be dressed without deranging 
the apparatus. A larger cicatrix was formed, and the girl re- 
covered without any deformity. 

When cicatrices, in consequence of a burn, gangrenous carbun- 
cle, or any other loss of substance, take place at the anterior- 
part of the neck, the skin is often overstretched, and frsena are 
formed, which keep the head bent and turned more or less to 
one side. In such cases, as in every other, the frsena must be 
cut, the lips of the wound separated and dressed with lint, 
and the head kept extended during the formation of the new 



j20 OF THE DEVIATIONS OF BONES, &C. 

cicatrix. The iron cross of Heister, and in general all the ma- 
chines proposed for remedying curvatures of the spine, may 
be employed for preserving the head in its proper direction. 

In contractions arising from the continual contracted state of 
the flexor muscles, it is often useful to contend against the 
force of these muscles, and bring the limb straight. This di- 
rection is the most favourable for the functions of the limbs, 
even when they are anchylozed. 

A young man, in consequence of an abscess which formed in 
the posterior and inferior part of the thigh, and which was fol- 
lowed by a great loss of the cellular substance of the ham, and 
of that about the popliteal vessels and nerves, had the biceps 
cruris, semitendinosus and semimembranosus muscles, so con- 
tracted, that the leg formed a right angle with the thigh. The 
leg could be extended by a force that overcame the contraction, 
but quickly reassumed the bent state on the removal of the 
force. Professor Boyer, convinced that in this case it was ne- 
cessary to contend unceasingly against a power that was always 
acting, had a machine constructed by Citizen Oudet,* which, 
by keeping the limb in a constant state of extension, both du- 
ring rest and exercise, at length overcame the contraction. 

* This ingenious artist, honoured by the approbation of the Academy 
•f Surgery, and esteemed worthy of national rewards, live in the street 
des Fosses Saint-Germain-des-Pies, Hotel de la Fautriere, Paris. The 
different apparatus for fractures of the clavicle, neck of the femur, and 
patella, an engraving and description of which are given in this work, 
have been constructed by him. 



ANALYTICAL INDEX. 



ABSCESSES ; the dimension of the opening made in them to be 
regulated according to their situation and cause, page 283. 
Alveolar process , partly (with one or more teeth) detached in a frac- 
ture of the superior maxillary bones ; treatment, 45. 
Anchylosis : distinguished into complete and incomplete, 310. 

seldom a primary disease, ibid. 

anchylosis from inaction arises from the diminution or cessation of 
the secretion of the synovia, 311. 

a case of complete anchylosis of all the joints might happen from 
long confinement motionless in bed, ibid. 

influence of the causes which produce this disease j as, from a bone 
fractured in the neighbourhood of a joint, ibid. 

the stiffness succeeding to fractures has been erroneously attributed 
to an effusion of osseous matter (36 and 37) into the interior of 
the joint, 312. 

mode in which anchylosis takes place, always the same, ib. 

the distinction of complete and incomplete essential to be observed 
in regulating the treatment ; when the former will ensue, such a 
previous disposition should be made of the parts as will be most 
convenient after its determination, ibid. 

— measures for prevention or removal of .the latter, 45, 313 and 

Aneurism : the laceration of a vein may be easily mistaken for a false 

primitive aneurism, 34. 
Apparatus by which a patient may raise himself in bed, 6j. 
Articulations. See the articles Dropsy; Foreign Bodies; 

White Swellings; and Wounds. 
Astragulusy may in some cases of luxation of the foot, be extirpated 
with advantage; instances, 286. 
fra&ures of this bone : See the article Tarsus, 
its luxations : See the article Foot. 

Bandages : their importance, in cases of fracture, to maintaining the 
fragments in the relative position, 25. 
their inefheacy, however, to preserve the fractured portions in just 

contact, 26. 
—examination of the different sorts of bandages, in this latter 

view ; 1 , the roller, ib. 
v — 2, the eighteen-tailed bandage ; its construction, and applica- 
tion : preferable to the former, ib. 
~— 3, Scultet's bandage ; its construction, and application, 27. 
.... — this, in most cases, superior to the other two, ib. 
the great use of bandages, ib. 
Bladder ; treatment of, when perforated by a splinter from a fracture 

of the pelvis, 67. 
Bones : cause of their hardness; and operation of this cause in the 
several wounds and disorders of the bones, 9 and 10. 
41 



322 ANALYTICAL INDEX. 

(Bones. Continued.) 

division of the diseases of the bones into two classes, 10. 
Buttocks : dangerous consequences of concealing violent falls on this 
part ; instance, 65. 

Calcis os : causes by which it may befra&ured; muscular action, or 
external violence, 152. 

— instance of the former Gase, ib. 

signs of this fracture, 153. 

method of setting, ib. 

— of keeping the foot and leg in the proper position, ibid. 

time of consolidation, ib. 

luxations. of this bone : See the article Foot. 
Callus: formation of; different opinions of the mode in which the 
consolidation of the fractured portions of bones is effected, 36. 

— opinion of the ancients ; ascribing it to the effusion of the osseous 
juice, 36 and 37. 

—a modern opinion ; attributing it to the periosteum, 37. 

—a true principle on this subject; analogy between what take*- 
place in the cases of a solution of continuity in the soft and in the 
osseous parts, 38. 

progress of the generation of callus, 39. 

—it is formed with more promptitude and facility in youth than 
in more advanced age, ib. 

— its formation how affected by extreme old age, or by difference 
of sex, ib. 

by the state of pregnancy, 40. 

local circumstances by which its production may be retarded ; by 
the want of a due quantity of blood to one of the fractured por- 
tions, ib. 

—by the surfaces of the fragments being not preserved in just con- 
tact and in perfect immobility, ib. 

usual period in which consolidation is effected ; vulgar prejudice 
on this subject, 41. 

— examine the state of the limb at the expiration of that period : 
treatment to be adopted in different circumstances of its appear- 
ance then; i* If it is swelled, or exhibits a tumour and is 
shortened and moveable, 41. 

2, if the pieces are moveable and separated, but no contraction, 
ib. 

— 3, if the fracture has not consolidated, but with a shortening and 
deformity of the limb :— when the ends pass each other, or the 
surfaces are partially in contact or totally separated, ib. 

when the portions continue very moveable on one another, 
though the just position has been preserved, 42. 

— In cases of not proper consolidation, after a term of several 
months, ib. 

—When, after using all other means, the pieces do not unite, last 
resource, of cutting off their extremities (see the article Extre- 
mities), 42 to 44. 

the patient is not to be at once allowed the free use of the limb after 
the reunion of the fracture, 44. 



ANALYTICAL INDEX. 2 2 3 

[Callus. Continued.) 
methods of removing a false anchylosis occasioned by the motion- 

^ss state of the member during cure, ib. 
Theformation of calius greatly retarded by the scurvy, 22. 
— it has even been observed to be destroyed by that cause, after 
it had been formed, 198. 
Caries. The nature of this disease much involved in obscurity, 
164. 
somewhat analogous to certain ulcers of the soft parts, ib. 
spongy bones, and those of young persons, most liable to it, ib. 
has been confounded with necrosis, and with exostosis ; its pecu- 
liar symptoms, and difference in this respect from necrosis, 
157, i6 s . 
its causes : distinguished into internal and external ; the former 

most frequent, 165. 
abscesses said to occasion sometimes caries; they are* however, 

in the cases alleged, its consequence and not its cause, ib. 
is seldom produced by an external cause, and may almost always 

be ascribed to a disease of the system, 166. 
—the operation of scurvy, as a cause of caries, ib. 
—of scrofula ; bones which it most frequently affects in this 
manner, ib. 

of the venereal disease, ib. 
of cancers of the mammae, ib. 
diagnosis, in different cases : as, in superficial, deep-seated, or in- 
accessible bones ; in constitutional disease* ; and in syphilis, 
— in caries of the vertebrae, ib. 
prognosis; most favourable in spongy bones, and in those of the 

167. 
carpus and tarsus, ib. 

—in affections of these latter, and in short bones in general, and 
in the extremities of long ones, amputation is frequently the only 
. resource, ib. 

caries from an external cause, less dangerous also than from an 
internal ; and of the latter, that from scrofula or cancer more 
dangerous than from lues and scurvy; more dangerous likewise 
to old than to young persons, 168, 
Treatment, very irregular : practice of the ancients, and of some 
moderns ; must be determined by a close view of the evil against 
whkh it is to be directed, ib. 
— if produced by an affection of the system, this to be ascertained 

and combated with appropriate remedies, ib. 
— if by an external cause, or remaining after the removal of the in- 
ternalone, apply stimulating, or absorbent and neutralizing, sub- 
stances, 169. 

but if these are ineffectual, use more active one?, which will 

reduce the part to the state of a simple necrosis, 169. 
m i' should the caries be very humid, the actual cautery must be 
resorted to, (except in certain cases) ; rules for its application ; 
itsmannerof action, 169 and 170, 
Modifications of this general treatment, in particular bones ; in the 
bones of the cranium, 171. 



3^4 ANALYTICAL INDEX. 

(Caries. Continued.) 

—(In the mastoid portion of the temporal bone the cautery is par- 
ticularly applicable, ib. 

—In the bones of the face, nose, and palate, ib. 

— In those of the antra maxillaria, 171. 

—In the os unguis; and scorbutic caries of the alveolar process 
ib. 

— In caries of the spine: its dangerous prognosis, 171 and 172, 

its symptoms, 173. 

■insufficiency of art in the treatment of this affection, ib. 

— In caries of the sternum ; rapid progress of the affection in this 
bone, and its dangerous consequences, 174.. 

—remarkable instance of a spontaneous recovery, ib. 

• treatment ; in the application of caustics, or of cutting instru- 
ments, ib. 

• — In caries of the ribs, or of the bones of the pelvis, 175. 

—In caries of the different parts of the iliac bone, ib. 

In caries of the extremities of long bone, ib. 

Its affinity with exotosis, which frequently terminates in caries, 1 77. 
Carpus; nature and treatment of fraSiures of, 93. 

luxations of its bones with those of its fore-arm, 259. 

these luxations may take place forwards, backwards, inwards, or 
outwards ; the first two sorts the most frequent, 260. 

peculiarity of the articulation of the hand with the fore-arm, in 
admitting of flexion and extension nearly to the same extent, ib. 

cause, and process, of luxation backwards ; its signs and method 
of reduction, ib. 

luxation orwards ; its cause ; it is rarely complete ; is difficultly 
distinguished from a sprain, all doubtful cases to be treated as 
luxations, ib. 

luxation either backward;:, or (particularly) forwards, accompa- 
nied wi-.h laceration of the ligaments, and followed by trouble- 
some inflammatory swelling; treatment after reduction, ib. 

luxation inwards, or outwards: never complete; its diagnosis; 
method of reduction ; the danger depends chiefly on the strain- 
ing and laceration of the soft parts, 261. 

Luxations of the bones of the Carpus and Metacarpus, ib. 

luxation of the head of the os magnum backwards ; inftance, and 
treatment, z6i and 262. 
Causes of fractures ; divided into predisposing, and remote, 18. 

the predisposing causes ; the situation of the functions of the bones ; 
instances, ib. 

— the age, and the diseases, of individuals ; instances, ib. 

- — a certain degree of cold improperly reckoned among these cau- 
ses, 19. 

the jenv'te causes, and their different operation, ib. 

• — 1, when the fracture is produced at a distance from the parts on 
which the force is applied ; instances, ib. 

—2, when produced exactly en the part struck; instance, ib. 
• case of comminutive fracture, ib. 

Causes of luxation ; are divided into external and internal; 
and both are predisposing or occasional, 207. 



ANALYTICAL INDEX. 21$ 

(Causes of lvx at ion. Continued.) 

1, the predisposing: are either natural or accidental : the natu- 
ral ; as, confirmation of the joint, ligaments, articulations. 
&c. ib. 

—the accidental ; as, disease, in various cases, 208. 

2, the occasional causes ; the effect of these depends upon the di- 
rection of the axis of the bone at the moment, 209. 

— in the round articulations, the action of the muscle has always a 

share in producing the luxation, 208. 
— in some cases, muscular action alone will effect a luxation, 209. 
luxations, from wnatever causes, always accompanied with lacera- 
tion or the ligaments surrounding the joint, 209. 
Children : caution against a dangerous manner of playing with 'hem ; 
in an instance of a fatal luxation of the vertebral thus occasi- 
oned, 227. 
See also the article Devi ations of the Bones, 
Clavicle: On the Fracture ot this bone; it is very liable to this 
accident, from various circumftances, 72. 
the fracture may be at any part of the length of the bone ; and ei- 
ther transverse or oblique, simple or differently complicated, ib. 
— fracture caused by cmtre-coup, is not necessarily complicated 

with contusion, ib. 
derangements of the broken portions, 73. 

» — mechanism of these derangements , the external portion is al- 
ways that which is deranged, ib. 
falling of the arm in a fracture, ib. 
signs of fracture, ib. 

by what complications these fractures are rendered dangerous, 74. 
examination of the various bandages invented for this fracture ; that 

of the ancients, ib. 
—that in the form of the figure 8. ib. 

different modifications of this latter, ib. 
the proper treatment, 75. 

—account of Desault's appropriate apparatus, J$ and 76. 
— improved invention of Boyer, jy. 

■ treatment of a simple fracture by means of this latter con- 
trivance, ib. 
treatment of compound fractures, ib. 
caution in using Desault's bandage, ib. 

On Luxations of this bone ; these are much less frequent than frac- 
tures, 235. 

1, of Luxations of the Extremity near the Sternum, ib. 

these dislocations are favoured by the conformation of the parts, ib. 

may take place forwards, backwards, or upwards ; but never 
downwards, 235. 

—the anterior most frequent; the others very rare, particularly 
the backward, 236, 

manner in which the anterior luxation is effected ; instance, ib. . 

— the upward, ib. 

—the backward, the treatment of this is difficult, 236. 

— Diagnosis of each, 238. 



3^6 ANALYTICAL INDEX. 

(Clavicle: luxations of. Continued.) 
the reduction to be effected in the same manner as in cases of frac- 
ture, 75, 238. 
—and the apparatus also the same, 77 and 238. 
2, of Luxations of the Extremity next the humerus, 239. 
these luxations very rare, and scarcely occur in any other direction 

than upwards, ib. 
—cause, and process, of dislocation in that direction, ib. 
—manner in which it is effected, ib. 
— diagnosis, 240. 

— prognosis, less dangerous than affirmed by Pare, ib. 
—-the luxation often imperfectly reduced, ib. 
— method of reduction ; bandage, 77 and 240. 
Instance in which a dislocation of this bone was mistaken for ex- 
ostosis, 178. 
Coccygis os\ seldom frafiured, 6 5 . 
signs of such an accident, ib. 
treatment, ib. 
dangerous consequences of concealing violent falls on the buttocks, 

ib. 
— instance, ib. 

Less easily luxated; instance, however, of this accident, 228. 
Cold improperly accounted a predisposing cause of fracture, 18. 
Comminuti<ve fraclure described, 12. 

treatments in various circumstances ; and cases in which amputa- 
tion is necessary, 34, 35, and 36. 
Complete and incomplete fraclures ; this distinctioa is unfounded, 17. 
Compound frafture defined, 17. 

treatment in the different cases of complication (See the article 
Treatment), 32 to 36. 
Consolidation of fraclures. See the article Callus, 
Contractions occasioned by burns ; treatment for, 319. 
—by the continual contracted state of the flexor muscles ; instance, 
320. 
Counter -extension. Seethe article Extension. 
Crepitation the most general and distinctive symptom of fracture, 20. 

methods of discovering the existence of this criterion, 20. 
Crutches; vast importance of a proper and sufficient use of them in 
recovery from a fracture of the lower extremities, 44. 

Demi-flexion ; comparative advantages and disadvantages of this po- 
sition, and of straightness, for a fractured limb during cure, 25. 
Denudation of the Bones. See the article Wounds. 
Derangement of the fractured portions of a bone ; its causes and va- 
rieties, 13. 
these latter considered : 1, In the direction of the diameter; and, 

2, parallel to the axis : instances of each, 14. 
3, the fragments forming an angle with each otner ; instances, ib. 
. 4, derangement affecting the circumference ; instance, ib. 
Causes of derangement ; always exterior : as, 1, the cause of the 
fracture; instances, (case of the celebrated Ambrose Pare), 15. 



ANALYTICAL INDEX. %T] 

—2, the weight of the limb, or the impulse communicated to it 

during the dressing, 15. 
—3, the most powerful, the contraction of the muscles (See the 

article Muscles), ib. 
Complicated derangements ; instance, ib. 
Deviations of the bones, and the deformity arising from 

them; can tak' place only in infancy, 314. 
their causes ; among which are the use of swaddling-clothes, and 

of stays, 315. 
— cases, however, in which stays of a certain construction may 

serve to correct disproportions, 316, 317. 
caution in the use of leading-strings ; in general they are injurious, 

by inducing the too early practice of walking, and thus ocasion- 

ing the knees to become turned inwards or outwards, 317. 
—-simple and efficacious method of remedy for this deformity, 3.18. 
deformity of the fee:, {club -foot t d : its different species: cause; 

necessity of early attention to ; and treatment, ib. 
treatment of contractions occasioned by burns, 319. 
— by the continual contracted state of the flexor muscles; instances, 

H. 
Differences of luxations, 23. 

1, with respect to the articulation ia which they take place ; much 
more frequent in the round or loose articulation than in the gin- 
glymoidal, 20<j. 

2, as to the extent of the dislocation ; distinction into complete and 
incomplete, ib. 

— the complete instanced in luxation of the humerus or femur, 204. 

— the incomplete, in dislocation of the head of the astragalus, ib. 

*— — an erroneous distinction of incomplete has been attempted to 
be established, 206. 

— the dislocation, when complete, may be to a greater or less dis- 
tance, ib. 

3, as to the direction in which the bone is displaced ; in the round 
articulations it may be in -the directions of all the radii of the 
circle, ib. 

limitations on this point, from circumstances of conforma- 
tion, ib. 
' " distinction of inferior, superior, &c. ib. 
— direction, in the ginglymoidal articulations, ib. 

4, as to the length of time they have continued ; a difference of 
the highest importance, 207. 

— a sufficient interval, may even have rendered the reduction im- 
possible, ib. 

5, as to the accompanying circumstances; which occasion the 
distinction into simple and compound, ib. 

6, as to the cause which has produced them : See the article Cau- 
ses of luxation. 

Differences cf fractures. See the article Species. 
Dropsy of the articulations (or Hydarthrus) ; occurs 
only in the knee, 288. 
. rarely co-exists with any ether dropsical affection, but is produced 
by local causes; their operation, 289. 



328 



ANALYTICAL INDEX, 



(Dropsy of the articulations. Continued.) 
-—may be occasioned also by acute or chronic rheumatism, and 

chronic gout, ib. 
collections of synovia sufficient to merit this name erroneously said 

to have occurred in the hip-joint, ib. 
this disease not to be confounded with encysted tumours on the side 
of the knee near the patella; (distinguished symptoms of 
these latter ;) nor with certain white swellings ; (this last mis- 
take may be easily made,) 290. 
distinguishing symptoms from arthritic, cedaraatcus, and white 

swellings of the knee, and foreign bodies formed in it, 290. 
prognosis unfavourable, 291. 

peculiar mode of treatment in this disease ; by topical applica- 
tions, 291. 
■ — if these means fail, a surgical operation to be resorted to ; this 
described, 292. 

after treatment, ib. 
Dura mater : tumour formed by fungous excrescences from this bone, 

may be mistaken for exostosis ; distinctive signs, 178. 
Eighteen-tailed bandage -, its construction, application, and compara- 
tive advantage, 26. 
Emphysema", its production, and treatment in different stages, 62 

and 63. 
Exostosis ; distinct species of, 176. 

different cases ; the ivory exostosis, the spungy, and that compo- 
sed of osseous and fleshy parts, ib. 
bones which are most frequently affected with this disease, ib. 
its different appearances ; almost always caused by lues or scro- 
fula ; its affinity with caries, and frequent termination in that 
affection, 176 and 177. 
• very rarely proceeds from an external cause, 177. 
signs of a scrofulus diathesis, ib. 
—of a venereal, ib. 

diagnosis ; peculiarity from that of a pericstcnS, ib. 
the existence of exostosis, sometimes cannot be ascertained before 

the patient's death ; instances, ib. 
the head of a luxated bone, the enlargement of the ends of ricketty 
bones, or the tumour formed by fur.gous excrescences from the 
dura mater, may all be mistaken for exostosis, 178. 
general effects of exostosis ; a sense of weight; pain ; and defor- 
mity, ib. 
^-particular effects: as, in exostosis in the orbit of the eye ; on 

the pubis ; or on any of the. bones of the pelvis, ib. 
Prognosis, different according to different circumstances ; exos- 
toses from an external cause more difficult than from an internal^ 
one ; of the latter, that produced by a scrofulus diathesis most 
so, ib. 
Erroneous opinions in the general pathology of this affection, 179. 
Principles of treatment ; the primary disease muse be afcertained, 

and made the chief object in this view, 179 and 180. 
if a venereal affection has existed, or is present, in the constitution, 
mild or strong applications of mercury. Sec. 180. 



ANALYTICAL INDEX. 3*1$ 

(Exostosis. Continued.) 

— after a certain time and effect, the general remedies to be dis- 
continued, ib. 

—caution in the use of mercury ; little reliance in these cases on 
topical applications, ib. 

treatment in scrofulous cases ; often ineffectual, ib.' 

—if the exostosis terminates in caries, the method of cure the 
same as if this latter had been the original affection, 181. 

the scorbutic and the cancerous, exostoses, ib. 

exostosis from an external cause, or merely local, should (after re- 
moving the primary disease) be left to nature ; rhe use of caus- 
tics, or the actual cautery, dangerous, ib. 

—treatment however, when the tumour presses on and deranges 
some important organ ; removal by the saw ; much preferable 
to the chisel and mallet, ib. 

direction for the use of these latter, when adopted, ib. 
this dreadful remedy seldom justifiable, 182. 

Lamellated exostosis, ib. 
Extension and counter-extension : not always necessary in setting a 
fractured bone ; instances, 23. 

the hands of intelligent assistants always best for both these pur- 
poses ; more powerful means injurious, ib. 

should be applied not on the fragments themselves, but on the 
bones which articulate with them 5 instances, 24. 

degree of force to be employed ; and its direction^ instances, ib. 

Apparatus for effecting perpetual extension, 29. 

its application and action, ib. 

—various rules on the former point, 30 and 31. 

sundry contrivances for effecting perpetual extension and counter- 
extension in fractures of the neck of the femur, 120 to 126. 

Some remarks respecting the method of making extension and 
counter-extension in a case of Luxation, 245 and 246. 
See also in the article Treatment (general) of luxations. 
Extremities of the fractured portions of the bones may be cut off, as 
a last resource when all other means fail of making them unite, 

this practicable only in the femur and humerus, ib. 

method of performing the operation, ib. 

— unsuccessful instance, 4.3 and 44. 

this operation very difficult, but not to be renounced for that rea- 
son, 44. 

May be practised also on the carious extremities in caees of white 
swellings of the joints, 307. 

—as, of the knee ; method, 308. 

— of the humerus, ib. 
instances, ib. 

• — instance, of the knee, 309. 

—great danger of this case, ii. 

■ — method, in the elbow, 310. 
iFemur. Luxations of the femur ; not frequent, and have been per- 
haps often confounded with fractures of the neck of this bone, 
264. 

42 



330 ANALYTICAL INDEX. 

(Femur. Continued.) 

divided into four species : i, luxation upwards and outwards; ano 
2, downwards ar>d inwards; these two the nv-st frequent, 264. 

— 3. iuxation upwards and forwards ; and 4, downwards and back- 
wards : very ian-, 265. 

the Fir:-t species considered : its process, il. 

— :cs symptoms, and distinctive diagnosis from fracture of the 
n^-ck of this bone, il 

■ cause of the limb being turned inwards in this luxation, 266. 

— much lacera'ion and injury done to the soft parts, ih. 
—method or effecting reduction, ih. 

signs of success in this operation, 267. 

after treatment, ih 

the Second species, downwards and inwards ; its causes, and pro- 
cess, 268. 

-7- ubsequent state of the soft parts surrounding the articulations, 
ih 

— diagnosis ; too striking to admit cf any mistake, ih. 

—prognosis, Jess unfavourable than in the First species ; method 
of reduction, 269. 

the Third species, upwards and forwards ; very rare ; instance^ 
however, il. 

— vmptoms, il. 

— irognosis dangerous s 270. 

— -luction, same as in the preceding species, ih. 

the Fourth species, dow* wards and backwards ; may be either pri- 
mary or secondary, ih. 
— general symptoms in both cases and peculiar ones in each, ih. 

— he secondary class muc . more frequent than the primary, 27c. 
— reduction, same as in the preceding species, ih. 

General caution in the reduction of these luxations, ih. 
cons-qutnees of luxations of the First and Second species, if not 

duc&J, 270 and 271. 
Spontaneous Luxations o" the Femur S^e that article. 
Instance of the carious extremity ok this bene and of the tibia cut 

. >ff in the case of white swelling, 309. 
Por Fractures cf this bone, See the articles Neck of the Fe- 
mur ; and Thigh. 
Fihula ; less frequently fractured than the tibia, 148. 

cause by which it i« exp sed to this accident ; action exerted on 

the fibula in walking on uneven ground, ih. 
formation and disposition of this bone in climbing animals, 140. 
manner in which it is fractured in the human subject, by the foot 
being forcibly turned inwards or outwards, ih. 
ires from a fall, or a biOw, 150. 
tcacu derangement, in all cases, ih. 
f;odoi t h". 

diagnoses, t u intense straining of the articulation of the foot, 

3n fra ctur t w. ation, some pra&isers confine their attention to 
and inflama. ving circumstances; dangerous consequences of 
these acompan. 
this treatment, is,. "h cas;s, 151. 

^$ roper method in »l 

■ 



ANALYTICAL INDEX. 3%t 

'Fibula. Continued.) 

time or' consolidation, 151. 

treatment of fractures towards the middle part of the bone, ib. 

fracture near the interior extremity a frequent complication of in- 
ward luxation of the foot ; treatment, 286. 

For fracture of loth bones of the leg, see the article Leg. 

The Luxation of this bone from the tibia is difficult, but may oc- 
cur : instance; treatment 283. 
fingers. See the article Phalanges 

Foot : 0\ Fractures of the Bones of ; See the articles Metatarsus % 
Phalanges (of the tees) ; and Tarsus. 

luxations of the foot ; seldom occur, on account of the confirma- 
tion of the parts, 284. 

may be either inwards, outwards, forwards or backwards ; and 
in each case complete or incomplete; the two foimer directions 
most frequent, particularly the first ; its cause and symptoms, 
284, 285. 

— symptcms of the outward luxation, 285. 

Luxations of the *oot aiways dangerous, and sometimes fatal % 
the prognosis, however, not always so unfavourable, ib. 

the reduction should be effected as soon as possible : method ; and 
after treatment, ib. 

the nature and violence of the symptoms decide with respect to 
amputation 5 the astragalus may m some cases be extirpated 
with advantage ; instances. 286. 

fracture of the fibula near its inferior extremity a frequent compli- 
cation of the inward luxation ; treatment, ib. 

cause* of forward and backward luxations ; the former more dif- 
ficultly produced, ib, 

-■ — process of each ; symptoms of the backward luxation; how 
distinguished from sprain, ib. 

symptoms of the forward luxation, ib. 

■ — reduction of both species ; and treatment, 287. 

The astragalus and os calcis never completely separated by luxa- 
tion, tb. 

— may, however, be disjoined (one or both) from the scaphcides 
and cuboides, ib. 

( ingenious idea of Chopart, of amputating only a part of 

the foot, ib. 

-—-causes of this luxation: it is often with difficulty ascertained ; 
and not easily reduced, instance, ib. 

the other bones of the tarsus and metatarsus cannot be luxated, 
288. 

See also the article Phalanges (of the toes). 

Deformity of the feet, {club-footed:) its different species; can$e ; 

necessity of early application ; and treatment, °3l8, 319. 
Fo a. E- AR m ; On Fraclures of, 83 . 

distinction ; into fractures of both, or of only or,«r, of the bones, 

84. 
1, Fractures of both the bones; generally take place in. the part 

ui which the cause has immediately acted, jb\ 



3J2 ANALYTICAL INDEX". 

(Fore-arm; fractures of. Continued.) 

the two bones may be fractured on the same, or on a different level ; 
the fractures are generally complicated, 84. 

species of derangement: that in the longitudinal direction, ex- 
tremely rare ; that in the direction of the diameter, ib. 

' — the angular derangement, ib. 

signs of fracture, ib. % 

■ — fracture near the inferior extremity, how distinguished from lux- 
ation, 85. 

setting the fracture, ib. 

application of compresses, bandages, and splints : the compresses 
and splints should be of the same length as the arm; lateral 
splints useless and injurious, 85. 

treatment of cases of excessive contusion, with wound or commi- 
nu ive fracture, 86. 

time of consolidation, ib. 

2, a^d 3, Fracture of the Radius or Cubitus only : See those ar- 
ticles. 

Of Luxations of the fore-arm, 25 1 . 

1, of Luxations of the fore-arm from the Humerus; they may be 

either backwards, laterally, or anteriorly : the first the most 

frequent ; the lateral much less so, and always incomplete; the 

anterior very rare, 251. 
process of the Backward luxation, 252. 
— this always takes place from a fall on the hand, ib, 
—situation of the parts after the dislocation, ib, 
— this luxation may be mistaken for fracture ; instance : the diag- 
nosis is difficult, ib. 
— different means of reduction; attended wiih inconvenience, 253. 
a preferable method, ib. 

■ after treatment, 253, 254. 

— -case of rupture of the ligament confining the head of the radius 

to the extremity of the ulna; treatment, 254. 
•—necessity of speedy reduction of these luxations, ib. 
luxation Forwards ; to be treated as a fracture of the olecranon 

(See that a~ticle). ib. 
luxation Laterally; method of reduction, ib. 
- — keeping the bones in their place, preventing, or mitigating,, 

the inflammation, 255. 
2, of Luxation of the Superior Extremity of the Radius frcm the 

Ulna, ib. 
this the most frequent of the relative dislocations of the bones of 

the fore-arm, ib. 
divided into primary and secondary luxations; the former class 

considered, «■*£. 
—cause of the backward being (in this case) more frequent than 

the anterior, luxation, ib. 
* — state of the parts in the backward luxation, 256. 

method of reduction ; and after-treatment, ib. 

—•Secondary luxation ; its causes, ib, 



ANALYTICAL INDEX. 233 

(Fore-arm; luxations of. Continued. 

— takes place frequently in young children, from the mischievous 
practices of nurses : treatment ; and consequences of neglect, 256, 

257. 
3, of Luxations of the inferior Extremity of the Ulna; this name 
adopted in preference to that (used by other authors) of Luxa- 
tions o- the inferior extremity of the radius, 257. 

these luxations may take place anteriorly or posteriorly ; the latter 
by much the most frequent, ib. 

— process of the former, ib. 

remarkable instance of this case, 258. 

—instance of luxation backwards, ib. 

its process, ib. 

method of reduction : and treatment, ib. 

this luxation less inconvenient in its consequences than that 

in the forward direction, ib. 
Foreign bodies formed in the articulations; to be 
carefully distinguished from arthritic concretions deposited in 
their neighbourhood, 293. 

may occur in the inside of every articulation in which there is ma- 
lion, but none more subject to them than the knee, ib. 

[The subsequent detail of circumstances and treatment, applica- 
ble only to those found in this joint.] 

their different appearances, number, size, form, and substance, ib, 

their origin and growth, difficult to explain; various suppositions 
on this point, 294. 

their different symptoms, and circumstances, ib. 

these substances cannot be resolved, nor (with advantage, if at all) 
fixed and confined, 295. 

extraction the best method of cure ; process of this operation, and 
after-treatment, ib. 

Case of these bodies in other joints, 297. 
Fractures ; natural cause of their superior tardiness in reuniting, 
beyond that of wounds of the flesh, 9. 

definition of fracture, 1 1 . 

See the articles Causes, Prognosis, Species, Signs, and Treatment, 
of Fractures; Callus ; and the names of the principal bones, 
Fragility ; state in which this disease appears in the bones, 197. 

it is a natural consequence of old age, 9, 10, 197. 

—at that period of life the disease is incurable, 198. 

sometimes occurs in adults, from a venereal, scrofulous, cr can- 
cerous taint, ib. 

— operation of the last cause ; remarkable instances, ib. 

— of the venereal taint ; in this case the primary disease claims ilier 
chief attention, ib. 

—of scorbutic affections, ib. 

• appearance of the bones of a scorbutic person, when boiled, 

ib. 

conclusion: fragility rather a symptom of senility or some disease, 
than itself a disease ; the etiology of Rickets may perhaps in 
sime be elucidated by a comparison of these two afFc&ions,, ib. 



334 ANALYTICAL INDEX. 

Hand; On the Fraclures and Luxations of the bones of. Seethe 
different articles Capus, Metacarpus ; and Phalanges of the fin- 
gers: 
Hanging-, different manner of dying, of the criminals hanged at Ly- 
ons and those at Paris; occasioned by a trivial custom of the 
executioner of the former place, 227. 
Hardness: cause of this peculiar quality of the bones ; and its pro- 
gress from infancy to mature age, 9. 
Humerus ; On the Fraclures of, 78. 

may be fraclured in any point of its length, ih. 

the fraclures may be either transverse or oblique, simple or com- 
pound, ih. 

— transverse fraclures, 78. 

— oblique fractures, ih. 

general diagnosis, 79. 

— fraclures in the neck of the humerus not so easily ascertained ; 
directions on this point, ih. 

different degrees of danger, in fraclures at different lengths of the 
bone, 80. 

operation of setting transverse or oblique fraclures ; bandage, 
Sec. ih. 

—the bandage must be applied on the hand and fore- arm, ih. 

positions of the arm; and general treatment, 81, 

— in cases complicated with violent contusion, :r cemminutive, ih. 

position of the splints, in fraclures of the lower extremity of the 
humerus; Boyer's praclice, 82. 

particular treatment; in fraclures of the neck of the humerus, ih. 

— Mcscati's method ; its great disadvantage, ih. 

— correcled by Le Dran, ih. 

— further improved by Default, ih. 

eminent merit of this improvement, 83. 

treatment of a case sometimes happening in young subjects, of the 
head of the humerus (whiie yet but an epiphysis) separating 
from the rest of the bone by a blow or fall, ih. 

compound fraclures not to be set till the inflammation has sub- 
sided, ih. 

Of Luxations of the Os Humeri, 239. 

equal in fiequency the luxations of all the other bones, ih. 

may take place in three direclions ; downwards, inwards or for- 
wards, and outwards or backwards : luxation upwards is impos- 
sible, ih. 

— the luxation even outwards or backwards scarcely occurs ; the 
other two species therefore merit chief attention, 239. 

the downward direclion more frequent than the inward or forward ; 
and in that case a subsequent change of place may carry the 
head of the humerus in this latter direclion, but cannot carry it 
backward, 240. 

1, Consideration of the downward luxation : causes which render 
this the most frequent direclion, ih. 

manner in which this luxation is performed, elucidated, 241. 

it has been thought that when the arm is moved out from the body, 



ANALYTICAL INDEX. ^3S 

(Humerus; luxations of. Continued.) 

the action or the deltoid muscle alone can produce a dislocation ; 

case cited, ih* 
state of the parts when the luxation has taken place, 24.2. 
diagnosis; marks by which the downward luxations are distin- 
guished from fractures of its neck, 79, 242, 243. 
prognosis, uncertain, 243. 
means to effect reduction ; enumeration and description of various 

which have fallen into disuse : the amle of Hippocrates, ih. 
— the ladder •, ih. 
— the process by the door, 244. 
— Petit's machine, ih. 

— the patient and the surgeon both extended on the floor, &c. ih. 
—or seated opposite one another, &c. ih. 
a more unexceptionable method, 244, 245. 
—if the first attempts fail, bleeding and warm bathing and repeat 

the operation ; in no circumstances puilies or other extending 

machines to be employed, 245, 246. 

useless and exquisite torture produced by the adoption of such 

mechanical contrivances, 246. 
erroneous supposition that the narrowness of the opening through 

which the head of the humerus has escaped resists it's reduction, 

ih, 
method of reduction after a certain interval has elapsed, 217, 246. 

2, Luxation inwards ; may be primary or secondary, 247. 
erroneous opinion, that the head of the humerus may be carried 

upwards towards the clavicle, and be placed between the great 

pectoral muscle and the subscapulars, ih. 
diagnosis, ih. 

prognosis; more unfavourable than in downward luxation, 248. 
« — means of reduction, nearly the same as in this latter, ih. 

3, Luxation outwards or backwards; no well-attested instance of 
this exists, though it appears to have been admitted possible, ih. 

cannot take place secondarily, and succeed to a luxation down- 
wards, ih. 

diagnosis, in the event of its occurrence, ih. 

• — means of reduction, ih. 

General treatment of each species: means of keeping the reduced 
bone in its place, ih. 

topical applications if necessary.; in contusions cf the shoulder; 
emollients, bleeding (in certain cases), and resolvents, 249. 

— in cedema of the arm ; its causes ; seldom occurs, ih. 

■ — in paralysis ; different treatment according to its different causes, 
ih. 
■sometimes confined to the deltoid muscle, ih. 

Tum>mr sometimes produced by the violent efforts necessary to re- 
duce an old luxation ; its nature, 250. 

Anchylosis never a consequence of luxations of the humerus when 
reduced, and even rarely when they are not reduced, 250. 

Method of cutting off the carious extremity of this bone (when the 
state of the soft parts will admit of it) in the case of white 
swelling, 308. 

—instance, 309. 



3^6 ANALYTICAL INDEX. 

Ilia (ossa), fractures cf. See the following article, 
Innominata ossa; these bones seldom fraftured, 66. 

the fracture may occur in different parts of them, and take diffe- 
rent directions, ib. 

no derangement of the portions ever takes place, ib, 

these fractures rendered very dangerous by extravasation and con- 
tusion, ib. 

their signs, ib. 

treatment, ib. 

— apparatus by which the patient may raise himself in bed, 67. 

the inflammation generally produces suppuration and abscesses, ib. 

detached splinters sometimes give rise to subsequent abscesses, ib. 

treatment if the bladder is perforated by a splinter, ib. 

These bones are too firmly articulated to admit of Luxation ; the 
articulations, however, may be relaxed to a certain degree, 230. 

question whether this relaxation is a means employed by nature to 
facilitate parturition, ib. 

— when the relaxation goes so far as to allow the bones to be moved 
and separated, it is rather a morbid than a natural state, ib. 

—instance of fatal sudden and easy delivery ; appearance of the 
ossa pubis and symphysis on dissection, 231. 

treatment in relaxation of the symphysis pubis, or of the sacro-iliac 
synchondrosis, 231. 

— a sudden and violent separation of the thighs not capable alone 
of producing a disjointing of the latter, ib. 

•— rhis may, however, be occasioned by external violence, in- 
stance, 232. 

these cases must be very rare : proper treatment ; the and* 

phlogistic, ib. 
Tschia fossa). See the preceding article. 
Jaw. See Lower j aw. 

Knee. See the article Dropsy of the articulations; Fo- 
reign BODIES FORMED IN THE ARTICULATIONS; and 

White swellings. 
Deformity of this part (of being turned inwards or outwards) fre- 
quently induce in children by the practice of too early walking; 
simple and efficacious method of remedy, 317. 

Leg ; On the Fractures of, 143. 

[his name com prises those fractures only in which both bones are 
broken ; the middle of each is the part generally fractured, ib. 

may be either transverse or oblique; and are liable to every sort 
cf derangement, ib. 

diagnosis, 144. 

prognosis, varies according to many circumstances; fractures near 
the knee, or the inferior part, more dangerous than of the mid- 
die; oblique fractures very difficult to be managed, ib. 

treatment of simple fractures : disposition of the patient; appara- 
tus, and its application ; bleeding, and low regimen, 144, 145. 

—compresses under the heel, not to be practised, 145. 



ANALYTICAL INDEX. 337 

(Leg ; fractures of '. Continued.) 

— roller, for very young children only, 145. 

the apparatus should be re-applied at the end of eight days, and 

afterwards every seven days ; dangerous practice of not changing 
the first dressing tor eighteen or twenty days, ib, 

— time cf consolidation, 146. 

— regimen, &>.. ib. 

in verv oblique fractures, continued extension should be employed, 
ib. 

For fractures of cither bone singly, see the articles Fibula ; and 
Tibia ; And for luxatious of the Bones of the Leg, see also those 
two articles. 
Longitudinal fradures, an inadmissible distinction, 13. 
Lower jaw ; kinds of Fratture to which it is liable; and their me- 
thod of producing the effect, 48. 

variations as to the part of the bone fractured, ib. 

— as to the direction of the fracture, ib. 

these fractures seldom simple, 49. 

— causes producing the derangement of the fractured portions; the 
complicated disposition and action of the muscles, ib. 

symptoms of fracture, 50. 

— in the branches and condyles, ib. 

these fractures in general not dangerous, il. 

— compound fractures, however, are so, ib. 

operation of setting a simple or double fracture, 5 1 . 

great difficulty of maintaining the fragments in the just position ; 
particularly of keeping the jaw motionless, on account of its na- 
tural functions, ib. 

— methods of feeding the patient, in this latter view, ib. 

— ligatures of gold or silver wire, unnecessary, and not of general 
utility, ib. 

— pasteboard moulds injurious, 51. 

— the use of bandages preferable ; method of applying them, 52. 

modification of this apparatus required in fracture of the con- 
dyles, 52. 

particular importance in fractures of the condyles to obtain a cure 
without deformity : effects of perverseness in the patient during 
the treatment j instance, 53. 

period of cure, 53. 

fracture with violent contusion, or a division of the soft parts, 53. 

On Luxations of the Lower Jaw; the distinction into complete and 
incomplete is erroneous, 220. 

these luxations can take place only anteriorly, ib. 

-—in very young infants, they are impossible in any direction, ib. 

the causes are almost always internal ; as, from excessive yawn- 
ing, 221. 

process of the luxation, ib, 

— theory of the mode in which it is effected ; ill-founded, ih t 

— a much better theory en this subject, ib. 

43 



33% ANALYTICAL INDEX. 

(Lower jaw; luxations of. Continued.) 

manner in which the parts surrounding the articulation are affect- 
ed, 222, 

diagnosis, ib. 

—these appearances much less distinct when a certain interval lias 
elapsed, 223. 

prognosis: vnucn 'ess unfavourable than that established by Hip- 
pocrates ; and not the more so in persons in whom the luxation 
is made with facility, ib. 

mode of ;e uction, ib. 

— a r ter-treatment, 224. 

method of reducing the luxation by fatiguing the muscles, 224. 

censurable pra&ice of reducing these luxations by a blow of the 
fist, ib. 

practice of the ancients, of using pieces of stick as levers between 
the great molares, to depress the lower jaw; the modern pro- 
cess preferable, ib. 

In dislocations of one condyle only, little modification of the treat- 
ment is required, ib. 
Luxation: rarely accompanies Fractures, 17, 32. 

—question of the treatment of such cases when they occur ; whe- 
ther the dislocated fragment should be first replaced, or not, till 
the consolidation of the fracture is effected, 32. 

the head of a luxated bone may be mistaken for exostosis; instance, 
in dislocation of the clavicle, 178. 

Luxation described : divided into complete and incomplete, 204. 
the previous anatomical knowledge necessary to consider the na- 
ture of this affection, ib. 
luxations afford both general and specific characters, ib. 
See the articles Differences ; Symptoms; Prognosis; and Treatment. 

Metacarpus : fratlures of these bones rarely occur, 93. 

these fractures always caused by a force immediately applied ; al- 
most in all cases several of the bones are fractured at once, ib. 
— case, however, of a fracture of a single one, 94. 
comminutive fracture frequently renders amputation necessary, ib. 
These bones are never luxated : the ligaments of their articulations 

may, however, be torn; treatment, 261. 
different liability of each bone to luxation, 262. 
Metatarsus; the bones of, susceptible only of comminutive/h?##r*, 

J 54- 
treatment, the same as those of the Hand, 93, 154. 

These bones cannot be luxated^ 288. 

Muscles: their powerful effects in the derangement of the fractured 

portions o' a bone, 15. 
three difT-rent cases of this; all instanced in the muscles of the 

thigh, ib. 

t, case of muscles attached to both the portions; instances, ib. 

—2, muscles inserted into the lower portion, or the limb with 

which it articulates ; instances, 16. 
—3, muscles inserted into the superior fragment; instance, ib. 



ANALYTICAL INDEX. 339 

Neck of the femur. ; On the Fractures of, i©2. 

these fractures most frequently take place in its middle part ; ex- 
ist within the articulation ; and are almost always transverse, 

a. 

—another species, which takes place outside the articulation, near 

the union of the bone with its trochanters, and sometimes be- 
tween these two eminences, ib. 
— instance, of fra&ure below the orbicular ligament, ib. 

remarkable instance, of a doubie fracture, one inside and 

one oucside that ligament, 103. 
fracture of the neck of the femur sometimes complicated with that 

of the great trochanter, very rarely with contusion ; may be 

comminutive, from a gun-shot wound, ib. 
case of decollation of the epiphysis, ib. 
— progress of os ification in the superior extremity of the femur, 

from infancy, ib. 
•. — possibility of this species of disjunction in the early p?rtof life; 

its diagnosis, treatment, and prognosis, 103, 104, 
predisposing causes of these fradlures ; brittieuess of the bones, 

vices of the constitution, caries, rickets, 104. 
—venereal disease, ib. 
exciting causes : a fall on the great trochanter ; or a fall on the 

feet or knees, 104, 105. 
—manner in which the fracture is produced in each of these two 

cases, 105. 
these fractures are never direct, but the contusion may nevertheless 

be considerable, ib. 
always attended with derangement, though this may not ensue for 

several days after the fracture, ib. 
— the delay in this circumstance may be produced by the resistance 

of the orbicular ligament, cr of the roughness of the surfaces of 

the pieces, 102, 106. 
— derangement in fractures within the articulation, and in those 

outside it, 106. 
— causes of derangement ; the weight of the body, but principally 

muscular acVion, ib. 
— derangement in the circumference 5 that in an outward direction, 

caused by the weight of the part, 107. 
that in an inward direction : its cause ; its possibility ascer- 
tained by observations ; its proportion to the outward direction, 

it. 

Diagnosis ; resemblance of the symptoms to those of luxation, has 

occasioned frequent mistakes, ib, 
the sensible signs alone to be depended upon, 1.08. 
— the shortening of the limb; cautions in ascertaining this sign, 

ib. 
— position of the foot, the knee, and the leg, ib. 

of the heel ; seldom placed so high as above the ankle of the 

o her foot, ib. 
— restoring the limb to its natural length and direction, and the 

foot to its position ; sensible signs observed in those operations, 

(crepitation, which is audible in the former ; and diminution of 



34-0 ANALYTICAL INDEX. 

(Neck of the femur: its fractures. Continued.) 

the arch described by the great trochanter, in the latter), 108, 
109. . 

— alterations in the appearance of the trochanter and of the but- 
tock, in fracture outside the articulation, 109. 

— impossibility of raising the member all at once, a constant sen- 
sible sign, 109. 

—a distinctive si^n proposed by Louis; unfounded, and otherwise 
inadmissible, 110. 

the signs by which the different species of luxation may be distin- 
guished from fracture ; 1, luxation upward and outward, ib. 

—2, luxation inward and upward, ib. 

— 3, luxations downward, ib. 

—4, the secondary or spontaneous luxation, ib. 

— -fractures, however, with very little or no derangement some- 
times difficult to be ascertained or distinguished ; instance, iil 

recapitulation of the distinctive sensible signs or fracture, ib. 

when doubt is. entertained, the apparatus should be applied, 112. 

Prognosis very difficult to establish, ib. 

difference- of opinion on that subject; importance of a right deci- 
sion on these, as it will direct the whole treatment, ib. 

1, opinion of those who affirm that the consolidation of the fracture 
cannot be at all effected ; arguments of the assertors of an os- 
seous juice (see p. 56), and of trie favourers o' Duhamel's the- 
ry (see p. 37) : both these parties answered, by facts and expe- 
rience, 112, 113. 

— argument founded on a want of a sufficient degree of vitality in 
the superior fragment; answered, by the instances relied on for 
its support having been drawn from cases of the complete rup- 
ture of the orbicular ligament, or of old age, 39, 113, 114. 

2, opinion of those who affirm that the shortening of the limb can. 
by no means be prevenred ; their different theories on the cause 
of this supposed inevitable consequence. 114. 

— writers by whom this opinion has been adopted : contradicted by 
many instances ; one adduced, 115. 

conclusion, ib. 

Motion of the parts to be particularly avoided during the treat- 
ment of these fractures, as tending to retard the naturally slow 
formation of the callus there, 1 16. 

Principal objects to which the attention should be directed in treat- 
ing these fractures: 1, setting the bone; application of the 
united force of several assistants in effecting extension, ib. 

— previously to extension, the derangement in the circumference 
should be corrected, ib. 

— coaptation totally useless, ib. 

— treatmenr, if on the first attempt at extension the muscles con- 
tract powerfully, 1 1.7.. 

2, keeping the pieces in their place ; difficulty o r this point, ib. 

— (question of the position considered: the half bent state to be 
totally rejected ; proper position, ib. 

•—numerous contrivances for this purpo"." ; examination of these: 
(first) of those which do not effect any extension, ib. 






ANALYTICAL INDEX. ,341 

(Neck of the femur; its fractures. Continue.!.) 
the spica bandage of the groin, 1 1 8. 
the eighteen-tailed bandage, assisted by the fanons or faux- 

fanons, ib. 
■ - long splints ; and some other expedients : all ineffectual, 

118, 119. 

method of Foubert; by continual resetting, 119. 

——method of Brunninghausen, ib. 
— (secondly) contrivances for effecting perpetual extension ; their 

application, and purpose, 120 
. the bed of Hippocrates ; and the Glosscomon used by the an-i 

cients, ib. 
method of Avicenna and others, of fastening the bands for 

extension to the head and foot of the bed, 120, I2f. 
——jse of a pulley and weight, 121. 

■ machine of Beliocq, ib. 

■——-machine of Hook, perfected by Aitken, ib. 
- particular account of Desault's apparatus ; and its applica- 
tion, 122, 123. Its disadvantages, 124, 125. 
improved and perfect apparatus of Boyer described ; and its 

application, 125, 126. 

-cautions in the use of the two last, 1 26. 

3, removing any unfavourable symptoms: topical applications; 

contusion and violent inflammation ; regimen, ib. 
Question whether in these fractures internal remedies ought to be 

resorted to for accelerating the consolidation ; as, rich gelatinous 

food, osteocolla, or spirituous liquors, 126 to 128. 
- — nourishment easy to digest, and spirits in moderate quantities, 

useful, 128. 
time of consolidation, ib. 

a stiffness in the articulation not much to be apprehended, ib. 
in some cases the improved method cannot be adopted, ib. 
consequences which would follow if the patient were abandoned tp 

nature, 129. , i 

For its Luxations, see the article Femur. 
Necrosis : strictly analogous to gangrene of the soft parts ; essen* 

tially different from caries, 157 to 164. 
bones which it most frequently attacks ; it may be either partial, 

or extend to the whole substance, 157. 
of long bones, the middle part is most subject to it ; and never the 

articulations, 158. 
when the necrosis is superficial, the superior lamella? are separated 

after a suppuration, ib. 
progress of the affection in a broad bon<?, ib. 
•—in complete necrosis of a long bone, ib. 
- separation of the periosteum from the diseased portion ; this 

is analogous to the process of mortification in the soft parts, but 

is performed much more slowly, 159. 
causes of necrosis ; internal, and external, ib. 
general diagnosis, 160. 






342 ANALYTICAL INDEX. 

(Necrosis. Continued.) 

prognosis ; varies, according to the bone affected and to circum- 
stances of complication, 160. 

— in partial, and in large, affections of flat or long bon^s, ib. 

— in cases where the dead bone is entirely included in that newly 
formed, ib. 

in this affection nature must be left to her own operations; the as- 
sistance of art is confined to extracting the dead portions, 161. 

treatment in necrosis of broad or flat bones; as, one of the large 
bones of the skull, ib. 

one of the bones of the cranium, 162. 

— of the exterior lamella? of a long bone, the same, ib, 

— in necrosis of the entire body of a lcng bone, 163. 

— — the extraction of the dead bone from within tne ossified peri- 
osteum in this case, is a painful and hazardous process, 163. 

method of performing this operation, when determined on, 

ih 

should not be had recourse to without the most mature delibe- 
ration, 164. 
Nose ; the bones of, much exposed to Fraclure, 46. 

most frequent kinds of fj-adtures, ib. 

case where the soft parts are not divided, nor the fragments dis- 
placed, ib. 

comminutive fradture; treatment, and operation, for its re-estah- 
li:>hment, 47. 

—in this fracture with depression of the splinters, the fragments 
should be adjusted without waiting the disappearance of the in- 
flammation, ib. 

fra&ure of these bones sometimes attended with very dangerous 
symptoms, ib. 

— this etiology, however, applicable only to persons advanced in 
age, tii 

Oblique frailure defined, 12. 

more dangerous than the transverse ; the greater the obliquity, the 

greater the danger, 22. 
Olecranon : analogy between the fractures of this bone and those of 

the patella, 89. 
— the former almost always occur at its base, and most frequently 

from some external force, ib. 
signs of these fractures, 90. 
— may be thus easily distinguished from a luxation of the cubitus 

backward, ib. 
treatment; application of compresses, bandages, &c. 90 to 91. 
time of re-establishment; gentle motion to be commenced earlier, 

9 1 ' 

grievous nature of compound fractures ; treatment, ib. 

protracted inflammation, 92. 

Osseous juice ; an effusion of, supposed by the ancients to be the efTi- 
cieat cause of the consolidation of fractures, 36, 37. 

Osteo-sarcom a : different species into which this disease is some- 
times divided, 182. 



ANALYTICAL INDEX." 343 

(Osteo-sarcoma. Continued.) 

i, the osteo-sarcoma, peculiarly so called, 183, 

2, the spina ventosa, or poedarthrocace, ih. 

general diagnosis, ih, 

each species is usually dangerous ; effect of venereal affections in 

producing it ; swellings of the phalanges of the fingers and toes 

are the least dangerous, ih. 
the treatment in aggravated cases; amputation, if practicable, 

184. 
in the real osteo-sarcoma, even ampution may be ineffectual to 

prevent a return of the affection, ih. 
renmkable instance of the second species ; in the conversion of the 

bones and surrounding parts into a gelatinous mass, 18410 187. 

Pare, Ambrose; his case, of a complicated fracture of the leg, 15. 
Patella; the Fradures of, may be either transverse or oblique, 
129. 

the transverse frequently occasioned by contraction of the extensor 
muscles of the leg, ih, 

—explanation why that cause dqes not rather rupture the tendon 
of the extensors of the leg, and the inferior ligament of the pa- 
tella, ih. 

this effect, in reality, is sometimes produced; but the symp- 
toms, prognosis, indications, and treatment, are the same in 
both cases, 130. 

— illustration of the manner in which the fracture of the patella is 
caused by these contractions; as, in the effort to resist falling, 
ih. 

— *the same violent contraction may be produced, and accompanied 
by the same effects, in leaping, and other exertions, 130, 131. 

fracture occasioned by falling on the knees, or by the violent im- 
pulsion of a body against the patella, 131. 

transverse fractures always attended with a separation of the frac- 
tured portions, though this may not immediately take place ; 
remarkable instance, ih, 

— this separation is produced by the concurrence of two causes ; 
the contraction of the extensor muscles, and the flexion of the 

• legj 1 .3 2 ' 
Diagnosis, very easy : as, falling without the power of rising, or 

of moving (when raised by others) except backward by draw- 
ing the feet along the ground ; instance, and treatment, ih. 

further signs: depression (instead of prominence) on the anterior 
part of the knee ; alterations producible in the relative position 
of the fractured portions, 133. 

Consolidation of these fractures: question whether this is effected 
by immediate reunion, or by means of a ligamentous substance, 
ih, 

authorities by which the latter theory is sanctioned, ih. 

the arguments for the former, 134., 

an instance: the theory of the intervention of a ligamentous sub- 
stance is well founded, ih. 



344 ANALYTICAL INDEX. 

(Patella. Continued.) 

the organization of the patella is in no manner different from that 
of other bones, and the peculiarities in the consolidation of its 
fractures arise from merely mechanical causes, 135. 

erroneous supposition ot Callisen as to the impediment to reunion 
of the fragments ; its sole occasion is in fact the impossibility of 
keeping them in contact by a proper apparatus, ib. 

nature of this ligament us substance, 136. 

— when it is long, it diminishes the muscular action, and the 
strength of the kr ee ; instances, ib. 

Objects of attention in the treatment; the principal is, the dimi- 
nution of the interval between the pieces, 137. 

previous means to prevent, or remove, inflammation: 1, the pre- 
ventatives, ib. 

« — 2, the remedies : immersion in cold water, useful ; leeches, in- 
jurious; wet compresses, 137. 

in cas^s of excessive contusion, 138. 

application of the apparatus when practicable : 1, position of the 
Jimb, 139. 

position alone, without confining the pieces, is insufficient, ib. 

—2, bandages ; that in the form of a figure 8 is inconvenient and 
injurious, ib. 

principles of a proper bandage, 140. 

■« its application, 140, 141. 

— soms advantage might be drawn from a knowledge of the nume- 
rous exploded apparatus, 141. 
—another apparatus desciibed, consisting of a trough, &c. ib. 

— method of seme authors, to use no sort of bandage, but permit 
the ligamentous substance to be lengthened ; mischievous effects 
of this treatment, 142. 
Of Luxations of this bone ; may take place in four directions, 278. 

1, downwards ; this can exist only with a transverse rupture of the 
tendon of the extensor muscles of the leg, ib. 

2, upwards ; this may depend on a rupture of the infericr liga- 
ment of the patella, 278. 

3, inwards; and 4, outwards: a predisposition to these may be, 
a great relaxation of the inferior ligament ; instance, 279. 

— of these two, the Outward is the most frequent ; its cause, ib. 
it may be favoured by a depression of the external condyle 
of the femur ; instances, ib. 

* instance of luxation in this direction occasioned by a gun-shot 
wound, rb. 

in this luxation the bone b easily replaced, but difficultly 
kept in its situation, 280. 

' the outward luxation may be either complete or incomplete : 

it is seldom complete : instances, however, ib. 

* symptoms, an J process, of outward luxation, ib. 

* — Inward luxation ; its symptoms, 281. 

Complete luxations can occur only in certain circumstances, ib. 

In every species, reduction to be effected as scon as possible ; me- 
thod, ib. 

— symptoms of reduction; and after-treatment, ib. 



ANALYTICAL INDEX. 345 

Pelvis: On the F 'rati ures of the bones of, 64. 

See the articles Coccygis ; Innominata ossa ; and Sacrum. 

artificial means are oi small effect in these fractures, and even ge- 
neral treatment not always efficacious, 6j. 

None of the assemblage of bones which form the Pelvis are suscep- 
tible of a true Luxation: S^e hewever, on this subject, the above- 
mentioned three articles, and also the article Ribs. 
Periosteum : theory which attributes to this membrane the consolida- 
tion of fractures, 37. 
Periostosis ; a species of exostosis, 176. 

its aistinguishing marks, from those of that disease strictly so call- 
ed, ib. 
Phalanges of the Fingers : the fracture of these bones always attended 
with contusion ; signs 01 fracture, 94. 

longitudinal derangement very rare ; the horizontal is almost the 
only one observed; operations of setting, and dressing, 95. 

time of re-establishment, ib. 

treatment in cases of the extremities being crushed, or bruised by 
* a folding door, ib. 

—if the last phalanx alone is crushed, miich better to amputate at 
Once, ib. 

oi luxations : the first phalanges may be luxated backwards, but not 
forwards, 262. 

luxations inwards can occur only in the first phalanges of the thumb 
and little finger ; outwards, in the first phalanx of the thumb 
alone, 263. 

this last-mentioned phalanx the most exposed to luxations back- 
wards ; their process, and signs, ib„ 
■their prognosis, ib. 

- these luxations should be quickly reduced ; method of opera- 
tion proposed by Default in a case of this kind, ib. 

the reduction not so easy as might be imagined, ib. 

method of reduction in various of these luxations ; and after-treat- 
ment, ib. 

See also 184, 303. 

phalanges of the Toes : susceptible only of comminutive fraclure, 

154. 
treatment, the same as those of the fingers, ib, 
cannot be luxated 'by externalviolefl.ee, 288. 
—but the first phalanx of the great toe may be luxated from the 
first bone of the metatarsus ; treatment, ib. 
Pcedarthrocace. See the article Oste o-sarcoma. 
Position ot a fractured limb during cure, 25. 
Pregnancy ; does not perceptibly retard the consolidation of a fracture, 

2 3> 4°- . 
relaxation of the articulations of the ossa innominata during preg- 
nancy : See the article Innominata ossa (luxations). 
Prognosis : of fraftures \ different according to various circumstances ; 
as, the bone fractured, the part of the bone, and the direction of 
the fracture ; instances of each, 21, 22. 
—according to the points of complication, 22. 
44 



'■ 



34-6 ANALYTICAL INDEX. 

{Prognosis. Continued.) 

— accord ing;[o the health and age of the individual ; instances, 22. 

In Luxation: dislocations in the round articulations much less dan- 
gerous than in the ginglymcidal, 211. 

the difficulty of reducing the luxated bone renders the luxation 
more or less troublesome, ib. 

luxations arising from certain distempered occasions have worse 
consequences than those from external violence ; and if accom- 
panied with particular circumstances of complication, render 
the prognosis proportionately more unfavourable, 212. 
Pubis ossa: See 'the arlicle Innominata ossa. 

Radius : fratlures of this bone more frequent than those of the cubi- 
tus, 87. 

usual causes of these fractures, ib. 

signs of fracture, ib. 

derangement, can only be in the direction of the diameter; the 
longitudinal, however, thought possible by Petit, 88. 

extension aud councer-extensicn, ib. 

caution in the applicant n of compresses and bandages, ib. 

method of cure, &c 84 and 88. * 

For luxations of this bone, see the article Fore-arm, 
Ribs ; On the Fractures of: the middle ribs most liable to this ac- 
cident, 59. 

the part fractured is generally, near the middle of the bone, 60. 

distinction of fractures into inwards and outwards, ib. 

possible complications, ib. 

signs of these fractures, ib. 

derangement of the fractjred portions: cannot take place in the 
direction of the diameu r of the bone, nor in that of its axis ; 
but only angularly, ib. 

— experiments on this subject, 61. 
_ treatment of simple fractures, either inwards or outwards ; band- 
ages, ib. 

—of cases where the violence has been considerable,^and the lungs 
contused or lacerated, 6z. 

—of the case of emphysema, in its different stages, 62, 63. 

the cartilages of the ribs ; the absurd practice for raising " de- 
pressed ribs" exposed, 63. 

luxations of the Ribs: cann:c cccur ; an instance which has been 
produced to the contrary, has been mistaken, and was in reality 
a simple fracture of the posterior extremity, 232. 

this name has been confounded with separations of the dorsal ver- 
tebrae from the head of the rib by'caries, 233. 

possible separation of the cartJiage of the sixth true rib from that of 
the seventh by contraction of the pectoralis major ; depression 
cf the other cartilages, and of the appendix xyphcides, 59, 63, 

2 33- 
Rickets : the enlargement of tie ends of bones of ricketty persons 
may be mistaken for exostosis, 178. 
persons who have suffered by rickets in their infancy, may be at- 
tacked again with this disease after puberty, 189. 



ANALYTICAL INDEX, 



347 



(Rickets.' Continued.) 
it sometimes affects the bones of the foetus, but most generally 

appears from the sixth or seventh to the fourteenth or fifteenth 

month after birth ; difficult cutting of the teeth has been consi- 
dered as a cause, 189. 
uncertain whether it is a primary affection, or a symptom of either 

scrofula, lues, or scurvy; a great connexion appears between 

it and scrofula, ib. 
progress of the disease, 90: 
— sometimes extends to produce caries in the ^ones, or white 

swelling in the joints, ib, 
the vertebral column particularly liable to this affection, ib. 
its effects, when general, on the different bones of the body, 191. 
conjectures, and queries, as to the proximate cause of rickets, ib% 
appearance of the different parts, an anatomical inspection after 

death, ib. 
opinions as to the cause of the curvature of the bones ; opinion of 

Glisson ; attributes it to the irregular accumulation of the hu- 
mours, 192. 
-*— of Mayow ; to the tendons being dry and shortened, ib. 
— nay be more probably deduced from the effect of the weight of 

the body, and muscular contraction, ih. 
hereditary in some families ; may in some such instances be traced 

to a venereal taint, ib. 
influence of dentition on the production or progress of this disease, 

considered, 193. 
— it is singular that the teeth preserve their hardness, ib. 
prognosis always unfavourable, ib. 
the crisis of puberty, or sometimes the diseases to which children 

are subject, arrest the progress of the complaint, ib. % 
treatment : no medicine of efficacy known ; general treatment 

principally advantageous, ib. 
— air, and diet ; exposure to the sun; materials of the bed, and 

position of the patient if very young; chairs; walking to be 

avoided, 194. 
— fri&ions useful, ib. 
— clothing, ib. 
—-qualities of nurses (of children at the breast) ; food for weaned 

children ; exercise, ib. 
particular remedies ; in complaints from dentition ; or in worms, 

J 95- 

— this last complaint very common in ricketty patients ; its signs, 
ib, 

means of discussing the swelling of the mesenteric glands ; tick- 
ling every day, to produce hearty laughter, very useful, ib. 

if proceeding in any degree from syphilis or scrofula, the treat- 
ment for those diseases to be recurred to, ib. 

it would be a principal object, if practicable, to restore the hard- 
ness of the bones, (see 9) ; madder Jtas no effect in this purpose, 
196. 

the great end thus, is to restore general health and strength, ib, 

mechanical means are ill adapted for tjhis disease, ib. 



I 






34-8 . ANALYTICAL INDEX. 

Roller', its inefRcacy for the purposes to which i: is applied in the 
treatment of fractures, 26. 

Sacrum ; this bone not much exposed XofraSiures, 64. 

treatment, in those accidents, ib. 

Not capable of luxation, 230. 

case of relaxation of the sacro-iliac synchondrosis : See the article 
Innominata cssa (luxation). 
Scapula : this bone not much exposed to fracture, from its posi- 
tion, 68. 

— its diffcrent*parts, however, vary in this respect, ib. 

these fractures always accompanied with conslderaole contusion, ib, 

the longitudinal fracture less frequent than the transverse, and 
causes very little derangement, ib. 

derangement in transverse fractures, or of the acromion and infe- 
rior angle, ib. 

—in fractures of the coracoid process, ib. 

signs of these different fractures ; the longitudinal, difficultly dis- 
tinguished, 69. 

— the transverse, more easily, ib. 

— the fracture of the inferior angle, manifested by the considerable 
derangement, ib. 

— that of the acromion, very easily, by a combination of circum- 
stances, ib. 

the contusion attending these fractures, the most dangerous symp- 
tom ; abscesses, ib. 

apparatus for fixing the arm steady during the cure, 70. 

treatme t in fractures of the inferior angle, ib. 

— of the acre mion, ib. 

time of consolidation, 71. 

• — in fractures of the acromion continue the bandage a little long- 
er, ib. 

general remedies ; as, blood-letting, &c. ih? f . 

these fractures seldom dangerous ; instance, however, in which it 

, was found necessary to trepan, ib. 
Scultet's bandage : its construction, application, and superior advan- 
tages, 27. 
Scurvy ; its powerful influence in retarding the consolidation of frac- 
tures, 22. 

app-arance of the bones of a scorbutic person, when boiled, 198. 
Signs of fractures : the sensible signs can alone give certainty of a 
fracture, 19. 

cautions in judging from the relative shortness of the limb, 20. 

judgments from the change of form and direction of the members, 
ib. 

derangement of the fragments sometimes perceptible by the fin- 
gers, ib. 

crepitation the most general distinctive symptom, ib. 

cases which preclude any certainty of decision : as, depth of fleshy 
parts; double bones ; cr inflammatory swelling, 21. 

—treatment on such occasions, ib. 

Signs of luxation* See the article Symptoms. 



ANALYTICAL INDEX. 349 

Simple fra&ure defined, 17. 

its general treatment, 32. 
Species of frattures ; distinction of five different, 10. 

1, as to the bone affected, 1 1 . 

— he broad bones not much exposed to this accident, ih. 
— the short ones still less so, and almost always by muscular con- 
traction alone ; ih. 
—the long bones very liable, ih. 

2, as to the part of the bones, 12. 

—in the point of bisection, generally ; mere or less near, or even 

at, the extremities ; or in different points at once, ih, 
—this distinction is of real and great importance, ih. 

3, as to the direction of the fracture, ih* 

. — the transverse, the oblique, and the comminutive fracture, ib. 
—the further distinction, of longitudinal fracture, is inadmissible, 

13- 

4, as to the relative situation of the fractured portions, ih. 

— causes and varieties of their derangement (See the article De- 
rangement), ih. 

5, distinction between simple and compound fractures ; descrip- 
tion of each, 17. 

Fractures are rarely accompanied with luxation, ih. 

they may be accompanied with, or may produce, other morbid af- 
fections ; instances, ih. 

the distinction of fractures into complete and incomplete is un- 
founded, ih. 

Species of luxations : See the article Differences. 
Spina <ventosa. See the article Osteo sarcoma. 
Spinal processes, marrow, &c. See the article Vertebrae. 
Splints ; their comparative utility in the treatment of fractures, 28. 

materials ; and length and construction for different parts, ih. 

their method of action ; they prevent derangements in the direc- 
tion of the diameter, angularly, and (if properly applied) in 
the circumference, ih. 

• — derangement in the direction of the axis in oblique fractures, 
and derangement in oblique fractures of the clavicle, almost im- 
possible to be prevented by splints alone, 29. 

importance of attention to filling the different inequalities and de- 
pressions of the limb with proper soft substances ; tape, as an 
external binding for the whole apparatus, preferable to strips of 
linen, 31. 
Spontaneous luxations of the femur; called also Secondary, 

2 7i- 

two principal varieties : First variety ; from the swelling of the 
cartilages, and the enlargement of the glands in the interior of 
the articulation, 272. 

1 — this variety may be produced by an external cause, ih. 

—its ordinary process, ih. ,. 

• — symptoms, and consequences, /ify* 

—appearance on opening the body after death, 273. 

Second variety, from caries of the circumference of the acetabu- 
lum, or head of the femur: its symptoms, progress, and ap- 
pearance on opening the jcir.r, 274. 



35° ANALYTICAL INDEX. 

(Spontaneous luxations. Continued.) 

Other causes of both varieties; scrofula especially, 274. 

— objections of those who think an internal cause absolutely neces* 
sary, ih. 

Petit's explanation of the manner in which these luxations take 
place, ib. 

-—futility of this explanation, 275. 

Prognosis; different according to the age and constitution of the 
patient, the species of luxation, its continuance, and cause, ib. 

Treatment: the principal object is to prevent the spontaneous lux- 
ation ; method, ib, 

— if a constitutional taint is suspected, the remedies must be di- 
rected to this, 276. 

—good effects of a large blister en the hip, ih. 

when these means fail, the progress of the disease should be arrest- 
ed by favouring the attachment of the head of the femur to the 
bones of the pelvis ; treatment, ib. 

—if, nevertheless, abscesses are formed, their opening should be 
retarded, 277. 

The luxation downwards and inwards less frequent than that up-* 
wards and outwards ; instance, however, of the former, ib. 

its treatment, and consequences, 278. 
Sprains; definition of this term, 199. 

different sorts of articulations more or less liable to this accident, 
ib. 

nature of the affection explained, ib. 

— appearances which immediately follow it, 200. 

time of re-establishment in cases of slight, or of more considerable, 
injury, ib. 

diagnosis, ib. . 

prognosis, unfavourable according to circumstances, 201. 

treatment, varies according to the continuance of the affection ; if 
adopted immediately, apply cold water or powdered ice for a 
considerable length of time, except in certain cases, ib. 

absurd practice of ignorant bone-setters, 202. 

the repellent mode cannot succeed if an interval of twelve hours 
has elapsed : treatment in Tthis case ; bleeding, emollient cata- 
plasms, resolvents, solvents, ib. 

—long inactivity, and posture, of the limb; application of a rol- 
ler, io. 

serious ultimate consequences of bad treatment in any respect, 203. 

dangerous nature of this affection, £0 trifling in the eyes of the vui- 
gnr, ib. 

treatment of the bad symptoms succeeding to sprains, ih. 

Sprain of the foot,4jpw distinguished from luxation backwards, 
287. 
Stays, a frequent cause of deformity in children, or of dangerous 
disease, 515. •, ma 

cases, however, in which stays of a certain construction may serve 
to correal disproportions, 316, 317. 
Sternum : this bone not much liable to fractarcs ; different way?, 
however, in which they may happen, 57. 



ANALYTICAL INDEX. 35 I 

(Sternum. Continued.) 

i, by extension operating on both extremities of the bone; in- 
stance (produced by the violent action of muscles), 57. 

2, by the immediate action of an external cause ; its attendant 
circumstances, 58. 

effusions of blood attending solutions of continuity, however abun- 
dant, seldom dangerous, ib. 

simple fracture ; its signs, and treatment, ib. 

complicated fracture ; treatment, ib. 

-—trepanning seldom necessary ; very great care in performing 
this operation, 59, 

affections of the appendix xyphoides, ib. 
Swaddling-clothes, a very productive cause of deformity, 315. 
Symptoms of luxation .* pain, and inability of moving the limb, equi- 
vocal symptoms, but not to be disregarded, 209. 

others, more decisive: 1, an elongation, or shortening, of the 
limb; both instanced in dislocations of the head of the femur, 
210. 

— 2, change in the direction of the bone; most easily distinguish- 
ed in recent cases, ib. 

change in the shape of the limb, ib. 

— 3, the impossibility of performing certain motions, 211. 

by these different circumstances a clear diagnosis is established ; 
frequency, and disgrace, of an error in this point, ib. 

Symptoms of fracture ; See the article Signs. 
Syno-via : its qualities have, in some cases, been considerably changed 
by the contact of air, so as to produce inflammation which ter- 
minated in a caries of the ends of the bones, 292. 

See also the Chapter on Dropsy of the Articulations, 288. 

Tarsus; On fracture of the bones of: of the os Calcis. See that 

article, 
the other bones susceptible only of comminutive fracture, 154.. 
treatment, the same as those of the Hand, 93. 154. 
For luxations of these bones, see the article Foot. 
Thigh. This member exposed to a great variety offraflures, 96. 
all the species of derangement may occur ; the longitudinal the 

most frequent ; action of the numerous muscles in producing 

these, 96. 
•—the muscular action in fractures above the condyles ; and, wherj 

the great trochanter is detached from the rest of the bone, ib. 
— -the angular derangement occasioned by the inclination of the 

foot, 97. 
aigns of fractures ; these accidents more dangerous in this than in 

any other limb, and require more unremitting care and atten- 
tion, ib. , 
some directions in this last point : dimensions and construction of 

the bed ; and disposition of the body of the patient, 98. 
— apparatus: bandages; compresses; splints, and their different 

lengths ; bags of chaff, to fill the intervals of the limb ; strings, 

or ribbands, 98, 99. 
—error of some practitioners in the application of bandages, 98, 



3S 2 ANALYTICAL INDEX. 

(Thigh : fraaures of. Continued.) 
— earliest treatment : arrangement of the apparatus, on the bed ; 

disposition and removal of the patient; setting, 99. 
application of the apparatus, ib. 
— subsequent treatment : bleeding, and regimen ; periodical re- 
moval of the apparatus ; time for final removal of the bandage, 

99, 100. 
in cases of oblique fracture, continued extension to be employed, 

100. 
treatment of very young children, ib. 
in fractures near the condyles, the hollow of the ham must be 

stuffed with lint, ib. 
compress and bandage in separation of the great trochanter from 

the rest of the bone, 101. 
time of consolidation, ib. 
—in very tedious cases, a stiffness in the articulation of the knee 

to be apprehended, ib. 
compound fractures, ib. 
See also the article Neck of the femur. 

For luxations of the Thigh, See the article Femur. 
Tibia : the fraBures of this bone are almost always transverse, and 
therefore not very dangerous, 147. 

if near the inferior extremity, no considerable derangement takes 
place, ib. I 

this last circumstance occasions the diagnosis to be often very dif- 
ficult, ib. 

usual means of ascertaining it, ib. 

treatment; setting, 148. 

time of consolidation ; the articulations are not injured, ib. 

For fractures of both bones of the leg, see the article Leg. 

luxations of the Tibia at its articulations wiih the condyles of the 
femur; may occur in four different directions, 282, 

— 1, backwards ; this always incomplete, and as often secondary 
as primary, ib. 

•—2, forwards ; more rare than the preceding, ib. 

3, and 4, laterally; inwards or outwards: these the most fre* 
quent, and always incomplete, ib. 

symptoms of the backward, and of the opposite, luxation, ib. 

—of the lateral luxations, 283. 

in every case of luxation tne reduction is easy ; method of prevent- 
ing a return, from the too great laceration of the parts, ib. 

the principal object of Treatment is the laceration of the soft parts : 
inflammation ; abscesses ; gangrene : perhaps a complete luxa- 
tion of the tibia from the femur may be considered as a case re-' 
quiring immediate amputation, 283 

Instance of the carious extremity of this bone and of the femur cut 
off in the case of white swelling, 309. 
Toes. See the article Phalanges. 
Transverse frafittfi defined, 12. 

less dangerous than oblique, 21. 
Treatment (genera!) of frafiures : first indication is to confine, or 
restore the fragments to their natural situation, 22. 



ANALYTICAL INDEX. 353 

{Treatment of fraftures. Continued.) 

— metn us of setting a fractured bone: extension and counter- 
extension, not always necessary. (See the article Extension) 

2 3> 2 4- • . 

second . dication: to maintain the portions in exact contact, and 
motionless, during the consolidation of the fracture, 24. 

— situation oi the limb: a horizontal plane; its adaptation, and 
materials, 25. 

—position of le limb; denr-flexion, 01 straightness : advantages 
<*rd uisajvantages of each ; the latter preferable, ih, 

— — necessity of pe.tect repose to the limb, ih. 

~— bandages (See that article), ib. 

— faux-fanons, splints (See that article), and apparatus for effect- 
ing perpetual extension (See the article Extension), 27 to 31. 

third indication ; to prevent any succeeding complication, 31. 
solutions proper to be applied to the parts, 32. 

— — reg men, ih. 

* — or, to remedy the different cases of complication when they have 
taken place, ih. 

as, 1, the case of fracture accompanied with luxation, ih. 

question whether the dislocated fragment should be first re- 
placed, or not, till the consolidation of the fracture is effected, 

33- 

2, when the soft parts are violently contused, without external 

wound, ib. 

3, when a vessel of a certain magnitude is opened by a frac- 
ture ; instance, ib. 

4, wounds occasioned by the penetration of the point of one 

oi the fragments through the integuments ; instance, 34. 

■ \ • wounds occasioned by the same causes as the fracture, as in 
comminutive fractures: treatment; the various circumstances 
and cases in which amputation is necessary, 3410 36. 

Treatment of luxations : principal indications to be fulfilled in this 
view; 1, To reduce the luxated bone, 212. 

this is effected by means of extension, counter-extension, and co- 
aptation, ib. 

i — Extension: part on which the extending force should be ap- 
plied ; advantage of the modern practice over the ancient in 
this respect, 213. 

objection to the former, ill-founded, ih. 

— means of effecting extension ; the hands of intelligent and strong 
assistants preferable to any mechanical means, ih. 

—-degree of force to be used ; to be varied according to circum- 
stances ; mechanical means never to be resorted to, 214. 
. — direction in which it is to be applied : should be at fi^t that 
which the luxated bone has taken; illustration of the necessity 
of this practice, ih. 

the bone to be gradually brought back to its natural position 
ih. 

— Counter-extension : part on which the force for this purpeje 
should be applied, 215. 

45 



J54 ANALYTICAL INDEX. 

{Treatment of luxations. Continued.) 

— means of effecting counter-extension ; the hands of the assistants, 
by the use of fillets, ib. 

— direction in which this force is to be made ; always perpendicu- 
lar to the surface of the luxated joint, ih. 

—the most intelligent of the assistant should be employed in ma- 
king extension, ib. 

— Coaptation ; easily performed when the extension is sufficient, 
ib. 

when the operations fail through insufficiency of the means em- 
ployed, these may be aided ekher by increasing t he number of 
assistants, or diminishing the muscular force ot the patient, 216. 

—-different ways of effecting the latter purpose ; by change of 
posture, ib. 

—by repeated bleeding, the warm bath, and very low diet, ib. 

—a state of intoxication favourable to this end ; it has ever 
been advised to intoxicate the patient in that view, ib. 

by fatiguing wi:h continual action the muscles surrounding 
the luxated bone; instances of this practice, ib. 

luxations that have, through mistake, continued several days be- 
fore application, difficult or impossible to be reduced: treat- 
ment; warm baths and pumping, exercise, and regular mo- 
tion of the iuxated bone, 217. 

— if a certain period has elapsed, and anchylosis has generally 
taken place, ib. 

signs of the luxation being reduced, ib. 

the practitioner should never be discouraged and despair in cases 
of recent luxation; perhaps none such are absolutely irreduci- 
ble, 218. 

2, To preserve the reduced bone in its place: perfect rest is the 
only requisite ; employment of bandages for this purpose, 218. 

luxation arising from any internal cause, ib. 

3, To prevent or remove the symptoms with which the luxations 
may be complicated ; enumeration of these causes ©Pcorsplica- 
tion, including fracture (See' 17, 32) ; treatment in each case, 
218. 

Consequences of luxations not reduced, 219. 

Vertebra: these bones not much liable to frailure-, when it does 

occur, the mere fracture is less dangerous than the consequent 

lesion of the spinal marrow, 54. 
—manner in which (in such a case) the effect on that substance is 

produced, ib. 
the diagnosis of these fractures is difficult to establish : some rules ; 

instance, 54, 55. 
the commotion or violent distension of the spine may produce the 

same effects as a fracture of this sort ; instance, 55. 
process of the fatal termination of these accidents, 55, 56. 
attempts at setting this fracture are useless ; general treatment the 

only resource, 54. 
—-treatment in flatulent distension of the abdomen, &c. ib, 
trepanning has been injudiciously recommended, 57. 






ANALYTICAL INDEX. 355 

(Vertebra. Continued.) 

fracture of the vertebrae, or affection of the spinal marrow, in the 

neck, produces speedy or instantaneous death, ib. 
—lesion of the fourth and firth cervical pair of nerves, ib. 

Of luxations of the Vertebrae; these dislocations in the dorsal and 
lumbar part of the column are impossible; but in the cervical 
vertebrae they may occur, 225. 

—instance, of a luxation lower down than the second vertebra, ib. 

Luxations of the Head from the first Vertebra, 226. 

cannot be occasioned by an external cause ; such an occurrence 
would destroy the individual, ih. 

may take place gradually and insensibly, ih. 

Luxations of the First Cervical Vertebra from the Second ; ren- 
dered easy by the conformation of the parts, ih. 

process of the luxation, ib. 

circumstances which sometimes render it fa:al, by a compression 
of the spinal marrow, 227. 

different manner of dying, of the criminals hanged at Lyons and 
those at Paris ; occasioned by a trivial custom of the executioner 
of the former place, ih. 

remarkable case of fatal luxation, from the niotflgn occasioned by 
the person himself; a caution against a dangerous manner of 
playing with children, ih. 

the relaxation of the ligaments of the tooth-like proce i may fa- 
vour this luxation ; in luxations of the neck which are not fatal, 
the dislocation takes place lower down than the second vertebra, 
228. 

— instances, ih. 

—•symptoms of these cases, 229. 

in luxations not indicating a compression of the spinal marrow, 
their reduction should not be attempted ; method of proceeding, 
however, when the patient insists upon it, ib. 

White swellings of the joints ; defined, 301. 

varieties: 1, the rheumatic ; its symptoms, progress, and conse- 
quences, 301, 302. 

occurs in various articulations, but principally in the knee, 302. 

—appearance on dissection, ib. 

—2, from a scrofulous taint: the various symptoms, progress, 
consequences, and appearance on dissection, ib. 

numerous forms of this disease in different patients, 236. 

seldom produced by an external cause ; sometimes occurs without 
any apparent cause ; in scrofulous persons it may follow external 
violence, 303. 

the enlargement of the ends of the phalanges, (183, 184,) belongs 
to this class of diseases, 303. 

the prognosis always unfavourable; less so in children under the 
age oi puberty, ih. 

a multiplicity of remedies have been proposed for this disease, ib. 

treatment, 304. 

— warm or mineral water, &c. kind of animal bath, 305. 



35 6 



ANALYTICAL INDEX. 



(White swellings of the joints. Continued.) 

— very violent means, as the actual cautery and burning with 
moxa dangerous, 305. 

—after- trc a tin nt, ib 

treatment in scrofulous cases, 305. 

daring practice of seme empirics, in employing acrid and stimu- 
lating applications; instance of entire recovery in this treat- 
ment, 305. 

treatment in cases of numerous abscesses, and considerable col- 
lections of pus, 306, 

amputation, when necessary; not to be too hastily resorted to, ih. 

— considerations determining on the propriety of this operation, 

—not to be performed but in cases where only one joint is affect- 
ed, a. 

practice proposed instead of amputation; of cutting off or extir- 
pating the carious extremities of the bones, when the state of the 
soft parts admits of it, 307- 

—cases in which alone this operation is practicable, 308. 

—method of performing it ; on the head of the humerus, ib, 

■ instances, 309. 

—proposed by Park to be extended to the articulations of the knee 
and elbow: but this is more hazardous: instance of his accom- 
plishing it on the former, ib. 
.— hs danger, and smai: comparative recommendations, 310. 

— method in performing it on the elbow, ib. 
Wounds, and Denudation, of the Bones; these two cases 
must be carefully distinguished, 154. 

if the bone is merely stript, replace the parts immediately and the 
periosteum will speedily reunite, ib. 

if the external laminae are contused, or its surface is long exposed 
to the air or to the friction of bandages, exfoliation takes place, 
and the integuments must not be prematurely closed, ib. 

treatment in each case : 1, in simple denudation, 155. 

—2, in cases of exfoliation : nature of this process, ib. 

— method employed to expedite the exfoliation ; oily relaxing ap- 
plications, 156. 

perforation for this purpose, injurious, ib, 

—incision sometimes necessary, to separate the detached portion, 
ib. 

3, in cases of complete division of the bone, ib. 

— the wound must be healed from the bottom, 157. 

— it' the bone is cut quite through, treatment and apparatus to be 
applied as in a case of fracture, ib. 

> and the time of reunion, and manner of consolidation, the 
same, 157. 

Wounds of the Articulations ; held to be dangerous, by all 
the ancient and almost all the modern writers, 297. 

instances, on the contrary, of their healing with the greatest fa- 
cility ; i, a wound in the elbow by a piece of glass which pe- 
netrated into the cavity of the joint, ib. 



ANALYTICAL INDEX. 357 

(Wounds, and Denudation, of the Bones. Continued.) 

—2, a wound in the same joint by a small sword, in which the 
capsule of the joint was opened, 298. 

instances that wounds by cutting instruments are not very danger- 
ous, even notwithstanding the admission of air : 1, the poste- 
rior part of the articulation of the wrist entirely opened, ib. 

—2, the same articulation opened, by a piece of a vessel of delf 
ware, ib. 

—3, the same articulation opened for about one third of its cir- 
cumference, ib. 

— The facility with which incisions are made to extract foreign 
bodies, also a proof of this, ib. 

the occurrence of inflammation in cases of the latter description, 
terminating in gangrene or ultimately in caries, must arise 
from long-continued and powerful action of the air, 299. 

—the imprudent application of dressings to the surfaces of the 
joint still more dangerous: instance, a sabre-wound on the ex- 
ternal side of the wrist filled with charpie, ib. 

—the danger equally great when the wound suppurates: instances ; 
— 1, a sabre-wound dividing the patella, ib. 

2, a sabre-wound on the anterior par: of the point of the 

shoulder, 299. 
■ 3, a sabre-wound in the inferior part of the arm, 300. 

conclusion; the prognosis of wounds in the articulations, in what 
circumstances favourable, ib. 

indications of cure, ib. 
Wrist. See the article Carpus. 

Zygomatic arch: case of its fracture (as, by the wheel of a carriage) ; 
treatment^ 45. 



NOTES. 



NOTE I. 

« THE apparatus for perpetual extension should not be applied 
before the irritation and spasm of the muscles are 'completely 
removed;" Page 29. 

There are certainly many cases in which this rule will hold 
good. But the spasmodic action of the muscles has frequently 
been removed by applying the apparatus for permanent exten- 
sion. In a case of oblique compound fracture of both bones of 
the leg, which occurred last winter in the Pennsylvania Hos- 
pital, under the care of Dr. Physick these disagreeable symp- 
toms were entirely done away by the application of the exten- 
ding splints invented by Dr. Hutchinson. A few hours after 
being applied, the splints by accident became displaced, in con- 
sequence of which the pain and spasmodic action returned. 
The patient was immediately relieved by again adjusting the 
splints. 



NOTE II. 

<c A man aged 36 had his arm fractured, and nothing was done 
to adjust the fractured bone. This arm had been so long use- 
less to the patient, that he was determined to undergo any trial 
for effecting the cure, &c." Page 43. 

In a case very similar to this, Dr. Physick pursued a different 
and more successful mode of treatment. Instead of sawing off 



j6o NOTES. 

the ends of the fractured portions of bone, a seton was passed 
between them. The wound went through all the different 
stages which are necessary to effect re-union in compound frac- 
tures. Inflammation and suppuration were succeeded by gra- 
nulations, which, by ossifying, produced a complete bony union 
at the end of thirteen weeks from the day on which the ope- 
ration was performed. The seton was removed at the end of 
the twelfth week. 

See a Paper by Dr. Physick, in the New- York Medical Re- 
pository, Hex. 2. vol. 1. p. 122. 



NOTE III. 

"If in a fracture of the superior maxillary bone, &c." Page 45. 

In the third volume of the London Medical Facts and Ob- 
servations a case is related, in which the ligatures as recom- 
mended by Le Dran were of very little use in retaining the 
fractured portions in their natural situation. This indication, 
however, was completely fulfilled, by placing a piece of sponge 
between the teeth of the upper and lower jaw. The gradual 
expansion of the sponge reduced the fracture in about thi? ty- 
six hours. The sponge was changed daily for about a month. 
Its use was then discontinued entirely, and the patient reco- 
vered soon after without any deformity, except the loss of the 
fore teeth. 



NOTE IV. 

"Paralysis induced by fractures - of the cervical vertebrae." 
Pages 55, 56, 57. 

Persons labouring under paralytic affections are very liable 
to gangrene, from long continued pressure. In other lingering 
diseases, the pain which the compression of any part occasions, 
generally compels the patient to change his position. In palsy 
however, this salutary warning is never given. But, how easily 
may we* guard against the evils that would result from this sus- 
pension of some of the operations of nature, by substituting 
those of art. All that is necessary is to change frequently the 
position of the patient. 



NOTES. 361 

The effect of pressure from the weight of the body, is not 
the only evil that we have to contend with in fractures of the 
cervical vertebrae. 

Muscular action is frequently the cause of the greater part 
of the dreadful consequences which almost invariably succeed 
fractures of these bones. The circumstance of their being so 
very moveable upon each other, will perhaps, in some measure, 
explain the fact, that injuries done to them are so frequently 
fatal. If the whole spinal canal were a complete and immove- 
able bony tube, fractures might sometimes take place in the 
spine, as they do in the cranium, without depression. 

But as this canal is composed of a number of distinct bones, 
each of which has strong muscles inserted into different parts 
of it, we cannot easily conceive, that a fracture of any of the 
true vertebrse can ever occur, without being accompanied with 
a compression of the spinal marrow. In what manner shall we 
endeavour to remove this compression ? Perhaps the best an- 
swer that we can give to this question will be to relate the fol- 
lowing case: 

Peter Colberry was admitted into the Pennsylvania Hospital 
on the 15th November, 1804. About half an hour previously 
to his admission, he fell from a height of ten feet, upon his 
head and back. 

The upper and lower extremities were paralytic, the head 
was turned a little to the left side, and the neck was somewhat 
contracted. The patient was unable to rotate the head upon 
the second vertebra, but could easily turn it in every direction 
by moving the whole neck. Upon making some extension a 
crepitation was felt in the cervical vertebrae. His pulse at this 
time was so much depressed as to be scarcely perceptible. On 
the morning of the 16th it became somewhat fuller, and the 
pain in the neck increased considerably. This symptom how- 
ever, was by no means so distressing, as a difficulty of breathing 
which came on about this time. The man was unable to cough, 
and was apparently almost suffocated by a collection of mucus 
in the trachea. Upon turning him so as to have the face 
downward, with a view of examining the vertebras, so great a 
compression was made upon the abdominal viscera, and dia- 
phragm, as almost to put a stop to respiration. 

Dr. Physick ordered an apparatus to be applied, by which the 
neck was kept extended. The feet of the patient were secured 
to the lower, and his head to the upper part of the bedstead. See 
Plate 1. fig. 1. 

46 



362 NOTES. 

Two hours after this dressing had been applied, the man reco- 
vered in some measure, the use of bis arms. The difficulty of 
respiration however, continued, and at 5 o'clock on the morning 
of the 17th he died. 

The muscles were not contracted, and the blood had not co- 
agulated. The spinous process of the fifth, and the body of the 
sixth cervical vertebra, were fractured, and pressed upon the 
spinal marrow. A considerable quantity of dark coloured coa- 
gulated blood was found between the spinal marrow and the 
membrane, which lines the cavity of the spine. 

The immediate cause of this man's death was, in all probabi- 
lity, a collection of mucus in the trachea, which a paralysis of 
the abdominal muscles, rendered him unable to discharge. 

Notwithstanding the fatal termination of this case, the cir- 
cumstance of the patient's being able to move his arms soon 
after the application of the apparatus, affords some ground for 
the belief, that in fractures of the cervical vertebrse, permanent 
extension of the neck may sometimes retain the fragments in 
their natural situation, and prevent them from pressing upon the 
spinal marrow. 

A delineation of this apparatus is given in Plate 1. fig. 1. 

A. A. Bandages passed round the ancles. 

B. Another bandage tied to the former, and secured to the 
upright piece C. at the foot of the bed. This serves to make 
the counter extension. 

For the extension a leather strap D. is passed round the head, 
and buckled on the vertex. E. another strap sewed to the 
former, and carried under the occiput. 

F. F. A bandage which ties the strap to the nut G. of the 
screw 2. 

Fig. 2. A male and female screw, invented and first used by 
Dr. James Stuart, in fractures of the leg and thigh. 

The use of this dressing is attended with several inconveni- 
encies. It is frequently necessary to move the body of the pa- 
tient — whenever this is done the extension will be rendered 
more or less oblique. It requires too much force, as almost all 
the ligaments and muscles of the whole body must be elongated. 

I have proposed an apparatus, Plate l.fig. 3, 4, 5, which may 
perhaps obviate some of these objections. 

Fig. 3. Two pieces of board about two feet in length, half 
an inch thick, and eight inches wide. The lower end should 
be excavated and covered with bolsters to receive the shoulders. 
Two mortises in the upper ends receive the cross pieces fig. 4. 



NOTES. 363 

Fig. 5. is a representation of the apparatus, when applied. 
Bandages, or leather straps, are passed round the head as in fig. 
1. carried through a hole in the first cross piece, and tied to 
the screw. 

If the screw should not be at hand, a common tourniquet 
will answer the same purpose. 

In fractures of the dorsal vertebrae, this dressing would be of 
no avail. For if a fracture occur in any part of the spine below 
the last cervical vertebra, it is evident, that the counter exten- 
sion must be made against some point below the first rib. If, 
instead of making the counter extension, as proposed by Dr. 
Physick, the ossa ilia should be chosen for that purpose, nothing 
is gained; as it is frequently necessary to raise the pelvis, and in 
doing this, an angle would be formed at the fractured part. 



NOTE V. 
■" Apparatus for fractures of the clavicle." Page 77. 

This apparatus is simple in its construction, and can be very 
easily applied. It fulfils every indication which should be at- 
tended to in the treatment of these fractures, except that of 
raising the arm. With a view of supplying this desideratum, 
and of rendering the dressing for a fractured clavicle still more 
simple, I have proposed a modification of Boyer's apparatus. 

As the construction and manner of applying it will be readily 
understood by taking a view of Plate 2. we need not enter into 
a lengthy description of it. 

Fig. 1. a cushion, to be placed under the arm. Fig. 2. a 
roller, about twelve inches in width, and four feet long, confines 
the cushion to the body. This part of the dressing has holes 
at each extremity, through which tapes are passed, and three 
loops L. L. L. Before the tapes are tied, the fore arm is to be 
carried through the middle loop, as at L. fig. 5. 

Thus the first bandage serves the double purpose of confining 
the cushion to the body, and of supporting the fore arm. To 
prevent the cushion from slipping downward, it may either be 
sewed to the roller 2, or supported by straps passed over the 
opposite shoulder. 

Fig. 3. another piece of linen, six inches wide, and about 
(ive feet in length. It is passed over the arm, and through the 



364 . NOTES. 

loops L. L. L. and tied behind with tapes. The straps A. B. 
fig. 5. which support the whole dressing, may be either passed 
through loops, or sewed to the first bandage, before and behind. 

Fig. 4. a bandage four inches wide, and a yard long, supports 
the elbow, and counteracts the tendency of the external frag- 
ment to be carried downward by the weight of the arm. 

The strap. C. D. prevents this bandage from slipping off the 
shoulder. 



NOTE VI. 
" Fractures of the Femur," Page 125. 

To the objections made by Boyer to Desault's splint, we may 
add the difficulty of preventing the foot from turning outward, 
and carrying with it the inferior fragment. 

A bandage passed round the foot, and tied to the internal and 
external splints, offers very little resistance. The internal splint 
being connected only by bandages to the rest of the apparatus 
is drawn outward by the weight of the foot. 

Another very great inconvenience in the use of Desault's 
splint is, that the bandages by which extension and counter ex- 
tension are made, act obliquely. This objection has been in 
some measure obviated by improvements made in the construc- 
tion of this splint by Dr. Physick, and Dr. Hutchinson. In 
Plate 8. we have endeavoured to give a view of these improve- 
ments. 

a. a. a. Represents the axis of the os femoris. 

D. The splint first used by Desault. 

d. d, d. The bandage which makes the counter extension 

against the tuberosity of the ischium. 

e. e. e. The bandage passed round the ancle, for the purpose 

of making extension. 

The dotted lines P. shew the addition made to the upper ex- 
tremity of this splint by Dr. Physick — p. p. p. the bandage 
which makes the counter extension. 

H. The block added by Dr. Hutchinson to the lower end of 
the splint, and h. h. h. the extending bandage passed round the 
ancle, and ever the middle of the block. 

The upper end of this splint is excavated, so as to resemble 
the head of a crutch, and covered with a cushion. The coun- 
ter extension is made against the axilla and the tuberosity oi" 



NOTES. 365 

the ischium. It is sometimes necessary to remove the bandage, 
in order to examine the perineum. Whenever this is done, 
the extension may still be continued, by making the whole of 
the counter extension against the axilla. 

The obliquity in the action of the extending and counter- 
extending bandages, is thus considerably diminished; but it is by 
no means entirely removed, nor is any provision made against 
the tendency of the foot to fall outward. 

Should the alterations which I am about to propose in the 
construction of Besault's splint be deemed worthy of a fair trial, 
future experience will determine whether they merit the name 
of improvements. Instead of the bandage which Desault di- 
rects to be passed between the scrotum of the affected limb, and 
tied to the external splint, for the purpose of making the 
counter extension, a piece of wood of an elliptical form, is 
made to surround the anterior and lateral parts of the thigh. 
This part of the apparatus, which for the sake of brevity shall 
be called the semi-circle, is to be placed on the thigh as in rig. 1. 
Plate 4. The external extremity presses against the spine of the 
ilium, while the internal compresses the tuberosity of the is- 
chium. 

R. R. shew two lateral projections pierced with holes. They 
should be about six inches in length, and parallel with the axis, 
of the os femoris. 

E. F. a handkerchief passed through a hole in each project 
tion, carried under the thigh, and tied at F. By tightening or 
relaxing this band, the circle may be in some measure enlarged 
Or diminished. 

Fig. 2, is a view of the apparatus applied to the left thigh. 

A. B. the splints of the usual length, and about seven in- 
ches in width. 

C. the semi-circle. 

c. c. c. e. four holes in the external splint, with the tapes 
which tie it to the external lateral projection. The internal 
splint is connected in the same manner, to the internal lateral 
projection, 

D. the cross piece upon which the extension is made by a 
bandage passed round the ancle. 

a. a. a. b. b. b. bags of chaff, somewhat wider than the 
splints. 

E. F. two cross pieces passed through mortises and secured bv 
pegs.^ They serve to keep steady the whole apparatus, and by 
pressing the bags of chaff against the limb, they prevent the foot 
from turning inward or outward. 



$66 NOTES. 

G. a bandage passed round the pelvis and external splint. 

The effects of pressure should be guarded against by ap- 
plying strips of adhesive plaister to the perineum, over the spine 
of the ilium, and round the ancle. A bolster should also be 
made to fit the upper edge of the semi circle. 

The bandage which passes round the ancle and is tied to 
the last cross piece, draws downward the inferior fragment, and 
at the same time, prevents the pelvis and superior fragment 
from descending, by pushing upwards the internal and external 
splints. By the former, the semi-circle is pressed against the 
tuberosity of the ischium, and by the latter against the spine of 
the ilium. In this manner, the extension, and counter exten- 
sion, are made in a direction parallel with the axis of the os 
femoHs. 



NOTE VII. 

" When the leg is fractured very obliquely, continued ex- 
tension ought to be employed." Page 146. 

The splints invented by Dr. Hutchinson are well calculated 
to fulfil this indication. They are so simple in their construc- 
tion, that a satisfactory description of them may be given with- 
out the aid of a plate. 

The splints are about four inches wide, and long enough to 
reach from the knee to some distance beyond the foot. The 
upper end of each has four holes. At the lower end they are 
connected by a cross piece passed through mortises. 

This apparatus is very easily applied. For the purpose of 
making the counter extension, two pieces of tape are bound to 
the inside, and two more to the outside of the leg, by a band- 
age passed round the limb, just below the knee. With these 
tapes, the upper ends of the splints are tied to the bandage. 
Another bandage passed round the ancle, and tied to the cross 
piece, makes the extension. 



NOTE VIII. 

" The extending force is to be applied to the inferior part of 
the leg, in order to have it as far as possible from the parts 



NOTES. 367 

which resist the return of the head of the femur. Luxations 
of the femur." Page 267. 

When we apply the extending force to the inferior part of 
the limb, as directed by Boyer, we must extend the leg. When 
this is done, the flexor muscles which originate from the pel- 
vis, and are inserted into the leg, have the same effect as if they 
were inserted into the os femoris — viz. they draw the head of 
the bone upwards, and offer a considerable resistance to the 
reduction. This resistance may be very much diminished by 
bending the leg. 

Two cases of luxated os femoris, came under the care of 
Dr. Physick last winter, in the Pennsylvania Hospital. In the 
first attempts which were made to reduce these dislocations, 
the extending bandage was placed above the knee. 

Whenever any considerable degree of extension was made, 
the bandage slipped. It was necessary then, either to pass the 
bandage round the ancle, and extend the leg-, or to flex the 
leg, and apply the bandage just below the knee. Dr. Physick 
preferred the latter, and soon after accomplished the reduction. 



POSTCRIPT. 



On the second of August, several days after the foregoing 
notes had been handed to the printer, the editor was called to 
a case of oblique fracture of the os femoris. The patient was 
a child aged two years and five months. Desault's splint was 
applied and had a very happy effect in lessening pain, by re- 
straining the convulsive action of the muscles. On the next 
clay however, the patient became extremely restless. The 
counterextending bandage had so much excoriated the perine- 
um, that every attempt to increase the extension gave great 
pain. 

In the afternoon, thirty-three hours after the accident, this 
dressing was removed, and the apparatus delineated in Plate 4< 
was applied. 

Dr. James Hutchinson very obligingly offered to witness the 
effects of this method of dressing fractures of the thigh. 

It was the opinion of this gentleman, that the necessary de- 
gree of extension in this case was made with little force, and 
consequently with little pain, in a direction parallel with the 



368 NOTES. 

axis of the os femoris: that the foot with the inferior fragment 
were effectually prevented from turning either inward or out* 
ward. 

The child is now (8th August) entirely free from pain, and 
no difference can be perceived in the length of the lower ex- 
tremities. 



THE END. 



PRACTICAL OBSERVATIONS IN SURGERY, 

ILLUSTRATED WITH 

CASES and PLATES: 
Br WILLIAM HEY, Esq. F. R. S. 

Member of the Royal College of Surgeons in London: Honorary Member of the Roya! 

Medical Society of Edinburgh ; and of the Literary and Philosophical Society 

of Manchester : And Senior Surgeon of the General Infirmary at Leeds, 



THE FOREGOING WORK 

Is in the Press of James Humphreys, printing on Subscription, 

On the following Terms : 

To make one volume, large octavo, on a handsome type and good pacer. 

The price to Subscribers will be three dollars for it in boards, and three dollars and 

a quarter bound j to be paid for on delivery. 
To non-subscribers the price will be increased as soon as published. 

The Anr.v.al Review, published under the direction of Doctor Aiken, speaking of the 
above JVork, says, 

" The abilities and experience of the ingenious Author of this 
work have already gained him considerable celebrity, and the 
publication now before us will be found to possess those claims 
to attentive consideration, which are derived from accurate ob- 
servation, sound judgment, and a perspicuous detail of interest- 
ing fafts." 

Subscriptions are received by said Humphreys, at his Eook-store on the Ex-- 
change, the Ccner of Second and Walnut-streets. 



